Carpal tunnel release. A prospective, randomized assessment of open and endoscopic methods

Sickness absence after carpal tunnel release: a systematic review of the literature

Objectives The aim of this systematic review was to provide an overview of time to return to work (RTW) after carpal tunnel release (CTR), including return to different occupations and working patterns. Methods A systematic search from inception to 2016 was conducted using nine electronic databases, trial registries and grey literature repositories. Randomized controlled trials and observational studies reporting RTW times after CTR were included. Study risk of bias was assessed using Cochrane risk of bias assessment tools. Time to RTW was summarized using median and range. Results A total of 56 relevant studies were identified: 18 randomized controlled trials and 38 observational studies. Only 4 studies were rated as having a low risk of bias. Reported RTW times ranged from 4-168 days. Few studies reported occupational information. Among 6 studies, median time to return to non-manual work was 21 days (range 7-41), compared with 39 days for manual work (range 18-101). Median time to return to modified or full duties was 23 days (ranges 12-50 and 17-64, respectively), as reported by 3 studies. There was no common method of defining, collecting or reporting RTW data. Conclusions This review highlights wide variation in reported RTW times after CTR. Whilst occupational factors may play a role, these were poorly reported, and there is currently limited evidence to inform individual patients of their expected duration of work absence after CTR. A standardized definition of RTW is needed, as well as an agreed method of collecting and reporting related data.

Neurologic complications in common wrist and hand surgical procedures

Nerve dysfunction after upper extremity orthopedic surgery is a recognized complication, and may result from a variety of different causes. Hand and wrist surgery require incisions and retraction that necessarily border on small peripheral nerves, which may be difficult to identify and protect with absolute certainty. This article reviews the rates and ranges of reported nerve dysfunction with respect to common surgical interventions for the distal upper extremity, including wrist arthroplasty, wrist arthrodesis, wrist arthroscopy, distal radius open reduction and internal fixation, carpal tunnel release, and thumb carpometacarpal surgery. A relatively large range of neurologic complications is reported, however many of the studies cited involve relatively small numbers of patients, and only rarely are neurologic complications included as primary outcome measures. Knowledge of these neurologic outcomes should help the surgeon to better counsel patients with regard to perioperative risk, as well as provide insight into workup and management of any adverse neurologic outcomes that may arise.

Outcome of Carpal Tunnel Release and the Relation With Depression

PURPOSE

To examine the relation between depressive symptoms and outcome of carpal tunnel release (CTR).

METHODS

Prospective study in a general hospital with data collection at baseline and 3 and 12 months after CTR. We quantified depressive symptoms using the Center for Epidemiologic Studies Depression (CES-D) scale and performed multivariable analyses on 2 outcome measures: (1) carpal tunnel syndrome (CTS) symptoms (Boston Carpal Tunnel Questionnaire [BCTQ]) and (2) palmar pain, focusing on preoperative CES-D and BCTQ score, sex, age, alcohol use, diabetes, and severity of nerve conduction abnormalities.

RESULTS

We included 227 patients. Before surgery, patients with depression had a higher BCTQ score than patients without depression. After 1 year, depressed patients had a higher BCTQ score and more palmar pain. The CES-D decreased by a median of 2 points from baseline to 1 year. This correlated with the decrease in BCTQ score. Multivariable analyses showed that preoperative depression had a small but statistically significant influence on palmar pain, but not on postoperative BCTQ score.

CONCLUSIONS

Depression is not an independent predictor of residual CTS symptoms 1 year after CTR. Depressive symptoms in patients with CTS decrease after CTR, along with a decrease in CTS symptoms. The nature of this relationship is unknown. Patients with CTS and depression may expect a somewhat higher degree of palmar pain after CTR, the clinical relevance of which is small.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Normal Palmar Anatomy and Variations That Impact Median Nerve Decompression

Annually, carpal tunnel release is one of the most commonly executed orthopaedic procedures. Despite the frequency of the procedure, complications may occur as a result of anatomic variations. Understanding both normal and variant anatomy, including anomalies in neural, vascular, tendinous, and muscular structures about the carpal tunnel, is fundamental to achieving both safe and efficacious surgery. Reviewing and aggregating this information reveals certain principles that may lead to the safest possible surgical approach. Although it is likely that no true internervous plane or so-called safe zone exists during the approach for carpal tunnel release, the long-ring web space axis does appear to pose the lowest risk to important structures.

A Clinical Study of the Modified Thread Carpal Tunnel Release

BACKGROUND

Previous studies have indicated that the thread carpal tunnel release (TCTR) is a safe and effective technique. Through a study on 11 cadaveric wrists, the TCTR procedure was modified and the needle control accuracy was improved to 0.15 to 0.2 mm, which is precise enough to preserve superficial palmar aponeurosis (SupPA), Berrettini branch, and common digital nerves. The aim of the present study was to verify the modified TCTR clinically.

METHODS

The modified TCTR was performed on 159 hands of 116 patients. The Boston Carpal Tunnel Syndrome Questionnaire was used for assessing the outcomes. Statistical analyses were used to compare the outcomes with the available data from the literature for the open and endoscopic techniques.

RESULTS

TCTR led to significant improvement in the short-term results, and the outcomes were better in long-term results compared with the open or endoscopic release. The SupPA, Berrettini branch, and common digital nerves were protected. There was no neurovascular complication for any case. Significant relief of symptoms was observed 3 to 5 hours post procedure. Most patients used their hands on the day of the procedure for simple daily activity. Patients reported their sleep quality was improved on the surgical day. Most patients with office jobs were able to return to work on postoperative day 1, and those with repetitive jobs returned to work in about 2 weeks. The statistical evidence proves that the modified TCTR procedure results in improved clinical outcomes as compared with open carpal tunnel release (CTR) and endoscopic CTR.

CONCLUSIONS

The TCTR procedure has been shown to be a safe and effective technique for CTR. The modified TCTR procedure minimizes postoperative complications, such as pillar pain, scar tenderness, or functional weakness, by avoiding unnecessary injuries to the surrounding structures around the transverse carpal ligament during the procedure.

Endoscopic carpal tunnel decompression: Comparison of mid- and long-term outcomes of 30 endoscopic and 30 standard procedure carpal tunnel decompression operations

Background:

Carpal tunnel syndrome is the most frequently seen trap neuropathy leads to pain, paresis, and weakness of hands.

Methods:

Totally, 60 patients who underwent endoscopic or standard CTS surgery in İbni Sina Hospital, Medical Faculty of Ankara university in the period of 2009 and 2012 were enrolled in this prospective study.

Results:

During 36 months, 60 patients had undergone hand surgery. Totally, 14 male and 46 female patients of this serial had an average age of 51.24 (22-74) years. A number of 26 patients (43%) had left and 34 had (57%) right hand surgery. Complete relief of nocturnal paresis and pain has been shown in the 6^th, 12^th, and 24^th month analyses of endoscopic surgery group results. Two patients in open surgery group underwent second operation due to relapse. The patients in the endoscopic group reported higher satisfaction cosmetically.

Conclusion:

Endoscopic carpal tunnel syndrome treatment is alternative and considerable option against standard open methods and due to low morbidity rates its performance is highly prevalent in recent years.

Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome-A Systematic Review

OBJECTIVE

To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results. Four systematic reviews and 33 RCTs were included. Surgery versus nonsurgical interventions, timing of surgery, and various surgical techniques and postoperative interventions were studied. Corticosteroid injection was more effective than surgery (strong evidence, short-term). Surgery was more effective than splinting or anti-inflammatory drugs plus hand therapy (moderate evidence, midterm and long-term). Manual therapy was more effective than surgical treatment (moderate evidence, short-term and midterm). Within surgery, corticosteroid irrigation of the median nerve before skin closure as additive to CTS release or the direct vision plus tunneling technique was more effective than standard open CTS release (moderate evidence, short-term). Furthermore, short was more effective than long bulky dressings, and a sensory retraining program was more effective than no program after surgery (moderate evidence, short-term). For all other interventions only conflicting, limited, or no evidence was found.

CONCLUSIONS

Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short-term, midterm, and/or long-term to treat CTS. However there is strong evidence that a local corticosteroid injection is more effective than surgery in the short-term, and moderate evidence that manual therapy is more effective than surgery in the short-term and midterm. There is no unequivocal evidence that suggests one surgical treatment is more effective than the other. Postsurgical, a short- (2-3 days) favored a long-duration (9-14 days) bulky dressing and a sensory retraining program seems to be more effective than no program in short-term. More research regarding the optimal timing of surgery for CTS is needed.

Carpal Tunnel Decompression. Is Lengthening of the Flexor Retinaculum Better than Simple Division?

This prospective randomized double-blind control trial compared lengthening and simple division of the flexor retinaculum in carpal tunnel decompression. Twenty-six patients with bilateral carpal tunnel syndrome were randomly allocated to have the flexor retinaculum divided on one side and lengthened on the other. All 52 hands were reviewed at regular intervals up to 25 weeks. The patients, therapists and the final reviewer were unaware of treatment allocation. The Levine symptom and function scores were used to assess the severity of the carpal tunnel syndrome and showed that the two treatments were comparable for relief of carpal tunnel symptoms. The two treatments were also similar for function measured with the Jebsen–Taylor test. There is no identifiable benefit in lengthening the flexor retinaculum when decompressing the carpal tunnel. Moderate or severe pillar and scar pain is common, occurring in 13 of 52 hands after surgery, but only in four by the 12th week and two by the 25th week.

Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release

BACKGROUND

Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost.

METHODS

We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test.

RESULTS

Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001).

CONCLUSIONS

Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique.

CLINICAL RELEVANCE

Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.

Simultaneous Bilateral Versus Staged Bilateral Carpal Tunnel Release: A Cost-effectiveness Analysis

The purpose of this study was to determine if simultaneous bilateral carpal tunnel release (CTR) is a cost-effective strategy compared with bilateral staged CTR for the treatment of bilateral carpal tunnel syndrome.

METHODS

A decision analytic model was created to compare the cost effectiveness of three strategies (ie, bilateral simultaneous CTR, bilateral staged CTR, and no treatment). Direct medical costs were estimated from 2013 Medicare reimbursement rates and wholesale drug costs in US dollars. Indirect costs were derived from consecutive patients undergoing unilateral or simultaneous bilateral CTR at our institution and from national average wages for 2013. Health state utility values were derived from a general population of volunteers using the Short Form-6 dimensions (SF-6D) health questionnaire.

RESULTS

Both surgical strategies were cost effective compared with the no-treatment strategy. Bilateral simultaneous CTR had lower total costs and higher total effectiveness than bilateral staged CTR, and had an incremental cost-effectiveness ratio of $921 per quality-adjusted life year compared with the no-treatment strategy. The conclusions of the analysis remained unchanged though all sensitivity analyses, displaying robustness against parameter uncertainty.

CONCLUSIONS

Surgical management is cost effective for the treatment of bilateral carpal tunnel syndrome. Bilateral simultaneous CTR, however, has lower total costs and higher total effectiveness compared with bilateral staged CTR.

LEVEL OF EVIDENCE

Economic and Decision Analysis I.

Z-Elongation of the transverse carpal ligament vs. complete resection for the treatment of carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome is treated successfully by surgical release of the transverse carpal ligament (TCL). However, persistent weakness of grip and pain over the thenar and hypothenar ends of this ligament, and "pillar pain", are reported to be common complications. In order to reduce these complications, different ligament reconstruction or lengthening techniques have been proposed.

OBJECTIVE

The purpose of this study is compare effectiveness and complications of TCL z-lengthening technique with complete TCL section.

METHODS

A prospective, randomised, intervention trial was conducted on 80 patients. The patients were divided into 2 groups: 1) complete release of TCL; 2) z-lengthening of TCL according to a modified Simonetta technique. Grip strength, pillar pain and clinical and functional assessment were carried out using the Levine et al. questionnaire.

RESULTS

No significant differences were observed (p>.05) in the postoperative reviews between the two groups as regards grip strength loss and pillar pain. There were significant differences between preoperative and postoperative mean Levine scores, but there was no difference in the mean scores of the two procedures at any time.

DISCUSSION

In conclusion, according to the results, TCL z-lengthening is more effective than simple division, but there is no identifiable benefit in z-lengthening for avoiding complications.

Revision Surgery after Carpal Tunnel Release –Analysis of the Pathology in 200 Cases during a 2 Year Period

Carpal tunnel release (CTR) is regarded as a common and successful operative procedure in hand surgery. However, an increasing number of patients with complications have been referred to our hospital. This retrospective investigation was undertaken to clarify the reasons for persisting or recurrent symptoms in 200 patients who underwent secondary exploration during a 26 month period at a single institution. In 108 cases, the flexor retinaculum was found to have been released incompletely. In 12 patients, a nerve laceration had occurred during the primary intervention. In 46 patients, symptoms were due to the nerve being tethered in scar tissue. The re-exploration revealed circumferential fibrosis around and within the median nerve in 17 patients and a tumour in the carpal tunnel in four patients. In 13 patients, no specific reason was found for recurrence of symptoms. We conclude that CTR seems to be a widely underestimated procedure and revision surgery could be largely avoided by reducing technical errors during the primary operation.

Validity and Responsiveness of the Patient Evaluation Measure as an Outcome Measure for Carpal Tunnel Syndrome

The aim of this study was to assess the validity of the Patient Evaluation Measure questionnaire (PEM) as an outcome measure in carpal tunnel syndrome. The PEM was compared to the DASH questionnaire and to objective measurements of hand function. We also compared its responsiveness to changes following carpal tunnel release with that of the DASH score. Twenty-four patients completed the PEM and DASH questionnaires before and 3 months after open carpal tunnel release. Grip strength, static two-point discrimination and the nine-hole peg test were measured. There was a significant correlation between individual items of the PEM and the objective measures. There was also strong correlation between PEM and DASH scores. The PEM showed a greater responsiveness to change (effect size 0.97) than the DASH score (effect size 0.49). The PEM correlates well with objective measures of hand function and the DASH score when used in carpal tunnel syndrome. It is more responsive to change than the DASH score. It is very simple to complete and score and is an appropriate and practical outcome measure in carpal tunnel syndrome.

Endoscopic Carpal Tunnel Release

We report our experience over a 30 month period of endoscopic release of the carpal tunnel by the Chow two-portal technique. The objective of this retrospective study was to evaluate the long-term subjective results of surgery and to assess if any iatrogenic nerve injury had been caused by the endoscopic procedure. The follow-up period was from 3 to 34 months. Our permanent, iatrogenic, postoperative nerve complication rate was 0.9% (2/208). No other serious complications occurred.

Postoperative Changes of Carpal Canal Pressure in Carpal Tunnel Syndrome: A Prospective Study with Follow-Up of 1 Year

Carpal canal pressures were measured in 103 patients with idiopathic carpal tunnel syndrome, before and after open release, with a postoperative follow-up of 1 year. Twenty-five normal subjects were used as controls. Pressures were measured with the wrists in three positions: neutral, full passive flexion and full passive extension. At each wrist position, the mean pre-operative pressures in the study group were significantly higher than in the control group. In both groups, the pressures were maximal with full passive extension and minimal in the neutral wrist position. Immediately after surgical release, there was a marked decrease of the carpal canal pressures. However, during the second postoperative month, there was a significant increase of the pressures at each wrist position, although these were still within the normal control range. This rise in pressures persisted to 12 months. These findings suggest that the carpal ligament reconstitutes by normal scar formation, but with lengthening such that the volume of the carpal canal is enlarged, so preventing a rise in pressure with return of the pre-operative problem.

Ultra-Minimally Invasive Ultrasound-Guided Carpal Tunnel Release: A Randomized Clinical Trial

OBJECTIVES

The purpose of this study was to compare the outcomes of 1-mm ultra-minimally invasive ultrasound-guided carpal tunnel release and 2-cm blind mini-open carpal tunnel release.

METHODS

We conducted a single-center individual parallel-group controlled-superiority randomized control trial in an ambulatory office-based setting at a third-level referral hospital. Eligible participants had clinical signs of primary carpal tunnel syndrome and positive electrodiagnostic test results and were followed for 12 months. Independent outcome assessors were blinded. Patients were randomized by concealed allocation (1:1) by an independent blocked computer-generated list. The postoperative score on the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire was the primary variable. Grip strength and time for discontinuation of oral analgesics, complete wrist flexion-extension, relief of paresthesia, and return to normal daily activities (including work) were assessed.

RESULTS

Ninety-two of 128 eligible patients were randomly allocated and analyzed. QuickDASH scores were 2.2 to 3.3 times significantly lower in the ultra-minimally invasive group for the first 6 months: 23.6 [95% confidence interval (CI), 20.5, 27.4] versus 52.6 [95% CI, 49.4, 57.0] at the first week and 4.09 [95% CI, 1.5, 7.1] versus 13.0 [95% CI, 9.4, 18.9] at 6 months. Return to normal daily activities occurred significantly sooner in the ultra-minimally invasive group: 4.9 [95% CI, 3.2, 6.5] versus 25.4 [95% CI, 18.2, 32.6] days.

CONCLUSIONS

Ultra-minimally invasive carpal tunnel release provides earlier functional return and less postoperative morbidity with the same neurologic recovery as mini-open carpal tunnel release for patients with symptomatic primary carpal tunnel syndrome.

Intraindividual comparison between open and endoscopic release in bilateral carpal tunnel syndrome: a meta-analysis of randomized controlled trials

PURPOSE

This study evaluated functional outcomes and safety after endoscopic and open bilateral carpal tunnel syndrome release in opposite hands of the same patients through a meta-analysis of randomized controlled trial data.

MATERIALS AND METHODS

Randomized controlled trials involving both methods in opposite hands of patients with bilateral carpal tunnel syndrome were identified via a systematic review of PUBMED and EMBASE.

RESULTS

Relative risks (RRs) and 95% confidence intervals (CIs) from five randomized controlled trials involving 142 patients with bilateral carpal tunnel syndrome were calculated using fixed- or random-effect methods, with a length of follow-up from 24 to 52 weeks after surgery. Compared with open release, endoscopic carpal tunnel release was associated with significantly better Boston Carpal Tunnel Questionnaire functional status scores (mean difference [MD] = 0.13, 95% confidence interval [CI] [0.02 - 0.25]; P = 0.02), but not symptom severity scores (RR = 0.06, 95% CI [-0.15 to 0.04]; P = 0.25). Endoscopic release required a longer operative time, but the procedures did not differ significantly in visual analog scale pain scores (MD = 0.02, 95% CI [-0.08 to 0.11]; P = 0.75), handgrip strength (MD = 0.17, 95% CI [-2.03 to 2.37]; P = 0.88), digital sensibility static two-point discrimination (MD = 0.34, 95% CI [-0.03 to 0.70]; P = 0.07), or complication rates (MD = 0.01, 95% CI [-0.02 to 0.05], P = 0.47).

CONCLUSION

From intraindividual evidence, endoscopic release promoted better recovery of daily life functions than open release, but required a longer operative time. The procedures provided similar symptom relief and hand strength and sensibility recovery, and were safe for patients with carpal tunnel syndrome.

Comparison of short wrist transverse open and limited open techniques for carpal tunnel release: a randomized controlled trial of two incisions

The purpose of this randomized controlled trial was to compare outcomes of limited open and short wrist transverse techniques in patients with carpal tunnel syndrome. In a single centre randomized controlled trial, 84 patients with idiopathic carpal tunnel syndrome were randomized before surgery to limited open or short wrist transverse open carpal tunnel release. The patients were evaluated at 6 weeks, 3 months, 6 months, and 1 and 2 years after surgery. At every follow-up, the Brigham and Women's Carpal Tunnel Questionnaire scores, scar discomfort, and subjective patient satisfaction were evaluated. Two years after surgery, five patients were lost to follow-up. The groups had similar Brigham and Women's Carpal Tunnel Questionnaire Symptom Severity and Functional Status scores and subjective satisfaction scores. The incidence of scar discomfort was not significantly different between the two groups on serial postoperative follow-up. Short wrist transverse open release surgery showed similar early postoperative symptoms and subjective and functional outcomes to limited open release.

LEVEL OF EVIDENCE

II.

Comparison of postoperative pain after open and endoscopic carpal tunnel release: A randomized controlled study

BACKGROUND

Results of open and endoscopic carpal tunnel surgery were compared with many studies done previously. To the best of our knowledge, difference in pain after endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) has not been objectively documented in literature. The aim of the study was to compare the pain intensity in the early postoperative period in patients undergoing OCTR versus those undergoing ECTR.

MATERIALS AND METHODS

Fifty patients diagnosed with carpal tunnel syndrome were randomized into two groups using "random number generator" software (Research Randomizer, version 3.0); endoscopic surgery group [(21 female, 1 male; mean age 49 years (range 31-64 years)] and open surgery group [(25 female, 3 male; mean age 45.1 years (range 29-68 years)] and received carpal tunnel release. Surgery was performed under regional intravenous anesthesia. The patients' pain level was assessed at the 1(st), 2(nd), 4(th), and 24(th) postoperative hours using a visual analog scale (VAS) score.

RESULTS

Mean age, gender and duration of symptoms were found similar for both groups. Boston functional scores were improved for both groups (P < 0.001, P < 0.001). Pain assessment at the postoperative 1(st), 2(nd), 4(th) and 24(th) hours revealed significantly low VAS scores in the endoscopic surgery group (P = 0.003, P < 0.001, P < 0.001, P < 0.001). Need for analgesic medication was significantly lower in the endoscopic surgery group (P < 0.001).

CONCLUSION

Endoscopic carpal tunnel surgery is an effective treatment method in carpal tunnel release vis-a-vis postoperative pain relief.

Endoscopic and Open Release Similarly Safe for the Treatment of Carpal Tunnel Syndrome. A Systematic Review and Meta-Analysis

BACKGROUND

The Endoscopic Release of Carpal Tunnel Syndrome (ECTR) is a minimal invasive approach for the treatment of Carpal Tunnel Syndrome. There is scepticism regarding the safety of this technique, based on the assumption that this is a rather "blind" procedure and on the high number of severe complications that have been reported in the literature.

PURPOSE

To evaluate whether there is evidence supporting a higher risk after ECTR in comparison to the conventional open release.

METHODS

We searched MEDLINE (January 1966 to November 2013), EMBASE (January 1980 to November 2013), the Cochrane Neuromuscular Disease Group Specialized Register (November 2013) and CENTRAL (2013, issue 11 in The Cochrane Library). We hand-searched reference lists of included studies. We included all randomized or quasi-randomized controlled trials (e.g. study using alternation, date of birth, or case record number) that compare any ECTR with any OCTR technique. Safety was assessed by the incidence of major, minor and total number of complications, recurrences, and re-operations.The total time needed before return to work or to return to daily activities was also assessed. We synthesized data using a random-effects meta-analysis in STATA. We conducted a sensitivity analysis for rare events using binomial likelihood. We judged the conclusiveness of meta-analysis calculating the conditional power of meta-analysis.

CONCLUSIONS

ECTR is associated with less time off work or with daily activities. The assessment of major complications, reoperations and recurrence of symptoms does not favor either of the interventions. There is an uncertain advantage of ECTR with respect to total minor complications (more transient paresthesia but fewer skin-related complications). Future studies are unlikely to alter these findings because of the rarity of the outcome. The effect of a learning curve might be responsible for reduced recurrences and reoperations with ECTR in studies that are more recent, although formal statistical analysis failed to provide evidence for such an association.

LEVEL OF EVIDENCE

I.

Endoscopic and Open Release Similarly Safe for the Treatment of Carpal Tunnel Syndrome. A Systematic Review and Meta-Analysis

Background

The Endoscopic Release of Carpal Tunnel Syndrome (ECTR) is a minimal invasive approach for the treatment of Carpal Tunnel Syndrome. There is scepticism regarding the safety of this technique, based on the assumption that this is a rather “blind” procedure and on the high number of severe complications that have been reported in the literature.

Purpose

To evaluate whether there is evidence supporting a higher risk after ECTR in comparison to the conventional open release.

Methods

We searched MEDLINE (January 1966 to November 2013), EMBASE (January 1980 to November 2013), the Cochrane Neuromuscular Disease Group Specialized Register (November 2013) and CENTRAL (2013, issue 11 in The Cochrane Library). We hand-searched reference lists of included studies. We included all randomized or quasi-randomized controlled trials (e.g. study using alternation, date of birth, or case record number) that compare any ECTR with any OCTR technique. Safety was assessed by the incidence of major, minor and total number of complications, recurrences, and re-operations.The total time needed before return to work or to return to daily activities was also assessed. We synthesized data using a random-effects meta-analysis in STATA. We conducted a sensitivity analysis for rare events using binomial likelihood. We judged the conclusiveness of meta-analysis calculating the conditional power of meta-analysis.

Conclusions

ECTR is associated with less time off work or with daily activities. The assessment of major complications, reoperations and recurrence of symptoms does not favor either of the interventions. There is an uncertain advantage of ECTR with respect to total minor complications (more transient paresthesia but fewer skin-related complications). Future studies are unlikely to alter these findings because of the rarity of the outcome. The effect of a learning curve might be responsible for reduced recurrences and reoperations with ECTR in studies that are more recent, although formal statistical analysis failed to provide evidence for such an association. Level of evidence: I.

The Cup of Diogenes: a fixed anatomical landmark for carpal tunnel surgery

PURPOSE

Carpal tunnel syndrome is a common entrapment neuropathy. When conservative management fails to relieve symptoms, carpal tunnel surgery is indicated. The surgical exposure for this procedure is commonly based on variable anatomic landmarks. The purpose of this study was to describe a fixed, easily referenced anatomical landmark for the distal extension of the transverse carpal ligament, the "Cup of Diogenes."

MATERIALS AND METHODS

Topographical landmarks including Kaplan cardinal line, palmaris tendon, and distal palmer crease were marked on six fresh frozen cadaveric wrist and hand specimens. The apex of the Cup of Diogenes is determined to be the confluence of the thenar and hypothenar musculature of the palm. Wrists were dissected and the distance between these landmarks and the superficial palmar arch, median nerve, transverse carpal ligament, and ulnar nerve were measured.

RESULTS

In all specimens, the ulnar nerve was ulnar to this the apex of the Cup of Diogenes, while the median nerve was radial. The apex was proximal in all specimens to the superficial palmar arch. The apex marked the distal extent of the transverse carpal ligament in all specimens.

DISCUSSION

Based on our results, we feel the apex of the Cup of Diogenes is a consistent, fixed anatomical marker for the distal extent of the transverse carpal ligament, marking a safe zone in the palm for surgical planning of incisions.

LEVEL OF EVIDENCE

Level V - Therapeutic.

Open carpal tunnel decompression by specialist versus nurse practitioner

PURPOSE

To compare the outcome after open carpal tunnel decompression by specialists versus a nurse practitioner.

METHODS

Of 1361 cases of open carpel tunnel decompression under local anaesthesia from 1996 to 2008, 807 were performed by specialists (consultant, specialist registrar, or specialty and associate specialist) and 554 by a nurse practitioner (since May 2006). The 2 groups were compared in terms of surgical time, total theatre time, postoperative pain, and patient satisfaction with the service.

RESULTS

The mean surgical time was shorter in cases performed by specialists (13 vs. 18 minutes, p<0.0001), as was the mean total theatre time (26 vs. 29 minutes, p=0.0154). The rate of postoperative pain was higher in cases performed by specialists (31.5% vs. 24.5%, p=0.0125), as was the rate of patient dissatisfaction (1.6% vs. 0.18%, 0.0113). Nonetheless, since May 2006, outcome was comparable for specialists and the nurse practitioner. This could be due to the change from short-acting to long-acting/mixed local anaesthetic, and the technique for infiltration. The waiting time for surgery reduced from a mean of 16 to 3 weeks.

CONCLUSION

Specialists and the nurse practitioner achieved comparable outcome after open carpal tunnel decompression.

Similar effectiveness of the open versus endoscopic technique for carpal tunnel syndrome: a prospective randomized trial

This prospective randomized study aims at evaluating the electrophysiological results of endoscopic and open carpal ligament release in patients with carpal tunnel syndrome. Included in the study were 41 patients diagnosed with carpal tunnel syndrome (21 hands in the endoscopic group and 20 hands in the open group). The Boston questionnaire was administered preoperatively and postoperatively to the patients, and their functional capacities and symptom severities were recorded. Physical examination was carried out preoperatively and in the postoperative sixth month. Demographic data and preoperative Boston symptomatic and functional scores were similar between both groups. A significant improvement was obtained in the Boston symptomatic and functional scores of both groups, but no significant difference was found between the groups in terms of improvement in the symptomatic and the functional scores. A significant shortening in median nerve motor distal latency and an increase in the velocity of sensory conductions were determined in both groups in the postoperative electromyography, but no difference was found between them in terms of improvement in the electromyography values. It was shown both clinically and electrophysiologically that endoscopic carpal tunnel surgery was as effective as open surgery as a treatment method for carpal tunnel syndrome.

Splinting after Carpal Tunnel Release: Does it really Matter?

Splinting of the wrist after carpal tunnel release (CTR) has been practised by many surgeons especially in North America. The main reason was to prevent possible adverse events of bowstringing of flexor tendons and the median nerve, pillar pain, entrapment of the median nerve in scar tissue and wound dehiscence. Studies on the effect of splinting after standard CTR have had dismal results. The duration of splinting in standard CTR has been either too long (for 2-4 weeks) or too short (48 hours only). The aim of our study was to compare the effects of post-operative splinting for a duration of one week with no splinting.

Methods: All 30 of our patients underwent a standardized limited open CTR by a designated surgeon. Post operatively, they were randomized into a splinted (n=16) and a nonsplinted (n=14) group. The splint was kept for a week. Patients were reviewed at regular intervals of one week, two months and six months. At each follow up, these patients were clinically assessed for the following outcome measures: VAS (visual analogue score), 2PD (two-point discrimination), pinch grip, grip, Abductor Pollicis Brevis (APB)) power and completion of the Boston questionnaire. Results: All patients presented with significant improvement in the postoperative evaluation in the analyzed parameters within each group. However, there was no significant difference between the two groups for any of the outcome measurements at sequential and at final follow-up.

Conclusion: We conclude that wrist splinting in the immediate post-operative period has no advantage when compared with the unsplinted wrist after a limited open carpal tunnel release.

Ultrasound assessment of the effectiveness of carpal tunnel release on median nerve deformation

To assess the biomechanical effect of carpal tunnel release (CTR), we evaluated the deformation and displacement patterns of the median nerve before and after CTR in carpal tunnel syndrome (CTS) patients. Sixteen wrists of 14 idiopathic CTS patients who had open CTR and 26 wrists of 13 asymptomatic volunteers were evaluated by ultrasound. Cross-sectional images of the carpal tunnel during motion from full finger extension to flexion were recorded. The area, perimeter, aspect ratio of a minimum enclosing rectangle, and circularity of the median nerve were measured in finger extension and flexion positions. Deformation indices, determined by the flexion-extension ratio for each parameter, were compared before and after CTR. After CTR, the deformation indices of perimeter and circularity became significantly larger and the aspect ratio became significantly smaller than those before CTR (p < 0.05). Those differences were more obvious when comparing the values between the patients before CTR and the controls. Since the deformation indices after CTR are similar to the patterns of normal subjects, the surrounding structures and environment of the median nerve may be normalized upon CTR. This may be a way to tell how the median nerves recover after CTR.

Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials

BACKGROUND

Carpal tunnel syndrome is a common compressive neuropathy of the median nerve. The efficacy and safety of endoscopic versus open carpal tunnel release remain controversial.

QUESTIONS/PURPOSES

The purpose of this study was to determine whether endoscopic compared with open carpal tunnel release provides better symptom relief, validated outcome scores, short- and long-term strength, and/or digital sensibility; entails a differential risk of complications such as nerve injury, scar tenderness, pillar pain, and reoperation; allows an earlier return to work; and takes less operative time.

METHODS

The English-language literature was searched using MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials that compared endoscopic and open carpal tunnel release were included in the meta-analysis. Methodologic quality was assessed with the Consolidated Standards Of Reporting Trials (CONSORT) checklist, and a sensitivity analysis was performed. Symptom relief, Boston Carpal Tunnel Questionnaire (BCTQ) scores, strength, digital sensibility, complications, reoperation, interval to return to work, and operative time were analyzed. Twenty-one randomized controlled trials containing 1859 hands were included.

RESULTS

Endoscopically treated patients showed similar symptom relief and BCTQ scores; better early recovery of grip strength (mean difference [MD], 3.03 kg [0.08-5.98]; p = 0.04) and pinch strength (MD, 0.77 kg [0.33-1.22]; p < 0.001) but no advantage after 6 months; lower risk of scar tenderness (risk ratio [RR], 0.53 [0.35-0.82]; p = 0.005); higher risk of nerve injury (RR, 2.84 [1.08-7.46]; p = 0.03), most of which were transient neurapraxias. Similar risk of pillar pain and reoperation; an earlier return to work (MD, -8.73 days [-12.82 to -4.65]; p < 0.001); and reduced operative time (MD, -4.81 minutes [-9.23 to -0.39]; p = 0.03).

CONCLUSIONS

High-level evidence from randomized controlled trials indicates that endoscopic release allows earlier return to work and improved strength during the early postoperative period. Results at 6 months or later are similar according to current data except that patients undergoing endoscopic release are at greater risk of nerve injury and lower risk of scar tenderness compared with open release. While endoscopic release may appeal to patients who require an early return to work and activities, surgeons should be cognizant of its elevated incidence of transient nerve injury amid its similar overall efficacy to open carpal tunnel release. Additional research is required to define the learning curve of endoscopic release and clarify the influence of surgeon volume on its safety.

Endoscopic versus open carpal tunnel release for idiopathic carpal tunnel syndrome: a meta-analysis of randomized controlled trials

The objective of this study is to do a meta-analysis of the literature and compare the safety and efficacy of endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) for idiopathic carpal tunnel syndrome (CTS). A comprehensive literature search of the electronic databases MEDLINE, EMBASE, Google Scholar, and the Cochrane Controlled Trial Register was undertaken for randomized studies reporting carpal tunnel syndrome treated with ECTR or OCTR. The quality of randomized trials was critically assessed. Pooled relative risk (RR) and 95% confidence intervals (CIs) for safety and efficacy outcome variables were calculated by fixed-effect or random-effect methods with RevMan v.5.1 provided by the Cochrane Collaboration. A total of 13 randomized trials were included by total retrieve and riddling. The results of our meta-analysis showed no significant difference in the overall complication rate (RR = 1.34, 95% CI [0.74, 2.43], P = 0.34), subjective satisfaction (RR = 1.0, 95% CI [0.93, 1.08], P = 0.92), time to return to work (mean difference = −3.52 [−8.15, 1.10], P = 0.14), hand grip and pinch strength, and the operative time (mean difference = −1.89, 95% CI [−5.84, 2.06]) between patients in the ECTR and OCTR groups (P = 0.16, 0.70, and 0.35, respectively). The rate of hand pain (RR = 0.73, 95% CI [0.53, 0.93], P = 0.02) in the ECTR group was significantly lower than that in the OCTR group. ECTR treatment seemed to cause more reversible postoperative nerve injuries as compared with OCTR (RR = 2.38, 95% CI [0.98, 5.77], P = 0.05). Although ECTR significantly reduced postoperative hand pain, it increased the possibility of reversible postoperative nerve injury in patients with idiopathic CTS. No statistical difference in the overall complication rate, subjective satisfaction, the time to return to work, postoperative grip and pinch strength, and operative time was observed between the two groups of patients.

Study to Assess Outcome After Open and Closed Carpal Tunnel Decompression

Carpal tunnel decompression (CTD) is the most commonly performed surgical procedure within a hand unit. We have analyzed data on outcomes after carpal decompression performed by both open and closed techniques to assess whether outcomes differed between the 2 procedures. Data were jointly gathered from 2 units. The aim was to assess the outcome after CTD. Completed data were gathered from 621 CTD procedures performed on 484 patients. Of the procedures, 358 were performed via a standard open CTD technique and 263 procedures were performed via a closed single-port Agee technique. Assessments were performed by means of the Levine-Katz questionnaire, Semmes-Weinstein monofilament testing, grip strength, and pinch-grip strength testing. Assessments were performed both preoperatively and 6 months postoperatively. A randomly selected 10% of patients were also assessed at 12 months. The results were statistically better after closed CTD at the 6-month postoperative stage. However, the difference became less marked by 12-month postoperative stage. Our results show that CTD whether performed by an open or closed technique resulted in a similar outcome at the 12-month postoperative stage. However, those procedures performed by a closed technique offered a more rapid recovery in the first 6 months postoperative than by an open technique.

Early major complications of endoscopic carpal tunnel release: A review of 1200 cases

Although the early benefits of endoscopic carpal tunnel release have been demonstrated, there is great controversy regarding the risks and safety of the technique. The present study reports early major complications in a series of 1278 consecutive cases performed by a single surgeon over a seven-year period. All procedures were performed under local anaesthesia on an outpatient basis using the Agee single portal technique. Mean follow-up was three months. No vascular, tendon or permanent nerve injuries were documented. Recurrent or persistent symptoms occurred in 7% of patients for which 20 of 89 underwent subsequent open carpal tunnel release. No nerve injuries were found on re-exploration. Other complications were consistent with previously reported incidences. This is the largest reported case series by a single surgeon and represents an accumulation of surgical experience at the upper end of the learning curve. Endoscopic carpal tunnel release is a safe procedure in this experienced single surgeon series.

Responsiveness of the Korean version of the Michigan Hand Outcomes Questionnaire after carpal tunnel release

Background

The Korean version of the Michigan Hand Outcomes Questionnaire (K-MHQ) was recently validated; however, the questionnaire's responsiveness as well as the degree to which the instrument is sensitive to change has not been thoroughly evaluated in a specific condition in Koreans. We evaluated the responsiveness of the K-MHQ in a homogenous cohort of patients with carpal tunnel syndrome (CTS) and we compared it with that of the Korean version of the Disability of the Arm, Shoulder, and Hand Questionnaire (K-DASH), which was found to have a large degree of responsiveness after carpal tunnel release for Korean patients with CTS.

Methods

Thirty-seven patients with CTS prospectively completed the K-MHQ and the K-DASH before and 6 months after surgery. The responsiveness statistics were assessed for both the K-MHQ and the K-DASH by using the standardized response mean (SRM), which was defined as the mean change of the original scores after surgery divided by the standard deviation of the change.

Results

All domains of the K-MHQ significantly improved after carpal tunnel release (p < 0.001). The SRM for all scales but one (the aesthetics scale) showed large responsiveness of ≥ 0.8. The aesthetics scale showed medium responsiveness of 0.6. The combined function/symptom scale of the K-DASH significantly improved after surgery (p < 0.001). The SRM of the K-DASH revealed large responsiveness of 0.9.

Conclusions

The K-MHQ was found to have a large degree of responsiveness after carpal tunnel release for Korean patients with CTS, which is comparable not only to the K-DASH, but also to the original version of the MHQ. The region-specific K-MHQ can be useful for outcomes research related to carpal tunnel surgery, especially for research comparing CTS with various other hand and wrist health conditions.

Effectiveness and safety of endoscopic versus open carpal tunnel decompression

PURPOSE

To evaluate the effectiveness and safety of endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) using a meta-analysis of data from randomized controlled trials.

MATERIALS AND METHODS

Electronic searches of the Cochrane Register of Controlled Trials (CENTRAL, Issue 11 of 12, Nov 2012), PUBMED (1980 to Dec 2012), and EMBASE (1980 to Dec 2012) were used to identify randomized controlled trials that evaluated endoscopic vs open methods for treatment of carpal tunnel syndrome. Studies to be used were independently identified by two researchers. The methodological quality of the studies was assessed by the Cochrane Collaboration tool for assessing risk of bias.

RESULTS

Fifteen randomized controlled trials involving 1,596 hands were included. Based on the Cochrane Collaboration tool for assessing risk of bias, four studies were rated as high quality, five studies were rated as moderate quality, and six were rated as low quality. Our meta-analysis indicated that ECTR resulted in better recovery of pinch strength, earlier time of return to work, but a higher rate of reversible nerve problems (including neurapraxia and numbness) than OCTR. ECTR also resulted in a lower rate of irreversible nerve damage (P > 0.05), wound problems (including wound infection, wound hematoma and wound dehiscence) and reflex sympathetic dystrophy (P > 0.05) compared with OCTR. Our meta-analysis revealed no obvious statistical differences in relief of symptoms (pain and paraesthesia), recovery of grip strength and reoperation rate.

CONCLUSION

Our meta-analysis of available randomized controlled trials demonstrated that ECTR and OCTR were similar in relief of symptoms, but ECTR resulted in better recovery of function and earlier return to work and was safer than OCTR.

Evaluation of patients with carpal tunnel syndrome treated by endoscopic technique

Objective:

To evaluate the postoperative results of patients with carpal tunnel syndrome by the endoscopic release technique with single portal.

Methods:

78 patients (80 wrists) were evaluated preoperatively and postoperatively at 1, 3 and 6 months by the Boston questionnaire, the visual analogue scale (VAS) for pain, monofilament test sensitivity, grip strength, lateral pinch, pulp to pulp pinch and tripod pinch.

Results:

Statistical analysis was significant (p <0.05) in the progressive decline of pain and improved function (Boston) during follow-up. The sensitivity significantly improved comparing the data pre and postoperatively. The grip strength, lateral pinch, pulp to pulp pinch and tripod pinch decreased in the first month after surgery, returning to preoperative values around the third month postoperatively.

Conclusion:

The technique proved to be safe and effective in improving pain, function, and return sensitivity and strength. Level of Evidence II, Prospective study

Concomitant endoscopic carpal and cubital tunnel release: safety and efficacy

BACKGROUND

When performed alone, endoscopic carpal tunnel release and endoscopic cubital tunnel release are safe and effective surgical options for the treatment of carpal and cubital tunnel syndromes, respectively. However, there is currently no literature that describes the performance of both procedures concomitantly. We describe the results of 17 cases in which dual endoscopic carpal and cubital tunnel releases were performed for the treatment of concurrent carpal and cubital tunnel syndromes.

METHODS

A retrospective review of all patients in a single surgeon practice that presented with concomitant ipsilateral carpal and cubital tunnel syndromes was performed. Within an 8-month period, 17 patients had undergone 19 concomitant ipsilateral endoscopic carpal and cubital tunnel releases after failing conservative treatment. Pre- and postoperative measurements included subjective numbness/tingling; subjective pain; manual muscle testing of the abductor pollicis brevis (APB), intrinsics, and flexor digitorum profundus (FDP); static two-point discrimination; quick-DASH (Disabilities of the Arm, Shoulder and Hand) scores; grip strength; chuck pinch strength; and key pinch strength. Complete data are available for 15 patients and 17 total procedures.

RESULTS

Thirteen male and four female patients (average age of 50.5) underwent dual endoscopic cubital and carpal tunnel release. Two patients were lost to follow-up and eliminated from data analysis. Pre- and postoperative comparisons were completed for median DASH scores, grip strength, chuck pinch strength, and key pinch strength at their preoperative visit and at 12 weeks. DASH scores improved significantly from a median of 67.5 to 16 (p = 0.002), grip strengths improved from 42 to 55.0 lbs (p = 0.30), chuck pinch strengths improved significantly from 11 to 15.5 lbs (p = 0.02), and key pinch strengths increased significantly from 13 to 18 lbs (p = 0.003). Average static two-point discrimination decreased from 5.9 to 4.8 mm. In terms of pain, 82 % of patients had complete resolution of pain, and the remaining 18 % experienced pain only with strenuous activity. In terms of numbness/tingling, 100 % of patients had complete resolution of median nerve symptoms; 88 % of patients had substantial improvement of numbness and tingling symptoms, and 12 % had residual ulnar nerve symptoms. In terms of muscle strength, 92 % of patients had improvement to 5/5 APB strength, while 100 % of patients had improvement to 5/5 intrinsic and FDP strengths. Two minor complications occurred, including one superficial hematoma and one superficial cellulitis.

CONCLUSIONS

Preliminary data demonstrate that dual endoscopic carpal and cubital tunnel release is a safe and effective treatment option for patients who present with concurrent cubital and carpal tunnel syndromes recalcitrant to non-surgical management. Postoperative results and complications are comparable to endoscopic carpal and cubital tunnel releases performed alone.

Carpal tunnel release using the Paine retinaculotome inserted through a palmar incision

BACKGROUND

Carpal tunnel syndrome (CTS) is the most commonly diagnosed and treated entrapment neuropathy. There is no consensus regarding the optimal technique for carpal tunnel release. The objective of this study is to demonstrate the surgical treatment of CTS by a small palmar incision and utilization of Paine retinaculotome to divide the transverse carpal ligament.

METHODS

In this technical note, we describe the use of a retinaculotome described by Paine in 1955, through a palmar approach.

DISCUSSION

Open, minimally invasive and endoscopic surgical techniques have all been described as treatment options for CTS, and short-term success with these methods is well established. During the last decade, less invasive techniques have been developed in order to reduce the incidence of pillar pain and tender scars. We have used a mini-palmar incision and the Paine retinaculotome for carpal tunnel release since 1994. The goals of surgery are to create a small incision that permits a patient to have early motion and return to activity.

CONCLUSION

After many years, no permanent nerve or vascular damage has been reported. This method has demonstrated itself to be efficient and safe in the treatment of the carpal tunnel syndrome.

Endoscopic release for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. It is caused by increased pressure on the median nerve between the transverse carpal ligament and the carpal bones. Surgical treatment consists of the release of the nerve by cutting the transverse carpal ligament. This can be done either with an open approach or endoscopically.

OBJECTIVES

To assess the effectiveness and safety of the endoscopic techniques of carpal tunnel release compared to any other surgical intervention for the treatment of CTS. More specifically, to evaluate the relative impact of endoscopic techniques in relieving symptoms, producing functional recovery (return to work and return to daily activities) and reducing complication rates.

SEARCH METHODS

This review fully incorporates the results of searches conducted up to 5 November 2012, when we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. There were no language restrictions. We reviewed the reference lists of relevant articles and contacted trial authors. We also searched trial registers for ongoing trials. We performed a preliminary screen of searches to November 2013 to identify any additional recent publications.

SELECTION CRITERIA

We included any randomised controlled trials (RCTs) and quasi-RCTs comparing endoscopic carpal tunnel release (ECTR) with any other surgical intervention for the treatment of CTS.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration.

MAIN RESULTS

Twenty-eight studies (2586 hands) were included. Twenty-three studies compared ECTR to standard open carpal tunnel release (OCTR), five studies compared ECTR with OCTR using a modified incision, and two studies used a three-arm design to compare ECTR, standard OCTR and modified OCTR.At short-term follow-up (three months or less), only one study provided data for overall improvement. We found no differences on the Symptom Severity Scale (SSS) (scale zero to five) (five studies, standardised mean difference (SMD) -0.13, 95% CI -0.47 to 0.21) or on the Functional Status Scale (FSS) (scale zero to five) (five studies, SMD -0.23, 95% CI -0.60 to 0.14) within three months postoperatively between ECTR and OCTR. Pain scores favoured ECTR over conventional OCTR (two studies, SMD -0.41, 95% CI -0.65 to -0.18). No difference was found between ECTR and OCTR (standard and modified) when pain was assessed on non-continuous dichotomous scales (five studies, RR 0.69, 95% CI 0.33 to 1.45). Also, no difference was found in numbness (five studies, RR 1.14; 95% CI 0.76 to 1.71). Grip strength was increased after ECTR when compared with OCTR (six studies, SMD 0.36, 95% CI 0.09 to 0.63). This corresponds to a mean difference (MD) of 4 kg (95% CI 1 to 6.9 kg) when compared with OCTR, which is probably not clinically significant.In the long term (more than three months postoperatively) there was no significant difference in overall improvement between ECTR and OCTR (four studies, RR 1.04, 95% CI 0.95 to 1.14). SSS and FSS were also similar in both treatment groups (two studies, MD 0.02, 95% CI -0.18 to 0.22 for SSS and MD 0.01, 95% CI -0.14 to 0.16 for FSS). ECTR and OCTR did not differ in the long term in pain (six studies, RR 0.88, 95% CI 0.57 to 1.38) or in numbness (four studies, RR 0.64, 95% CI 0.31 to 1.35). Results from grip strength testing favoured ECTR (two studies, SMD 1.13, 95% CI 0.56 to 1.71), corresponding to an MD of 11 kg (95% CI 6.2 to 18.81). Participants treated with ECTR returned to work or daily activities eight days earlier than participants treated with OCTR (four studies, MD -8.10 days, 95% CI -14.28 to -1.92 days).Both treatments were equally safe with only a few reports of major complications (mainly with complex regional pain syndrome) (15 studies, RR 1.00, 95% CI 0.38 to 2.64).ECTR resulted in a significantly lower rate of minor complications (18 studies, RR 0.55, 95% CI 0.38 to 0.81), corresponding to a 45% relative drop in the probability of complications (95% CI 62% to 19%). ECTR more frequently resulted in transient nerve problems (ie, neurapraxia, numbness, and paraesthesiae), while OCTR had more wound problems (ie, infection, hypertrophic scarring, and scar tenderness). ECTR was safer than OCTR when the total number of complications were assessed (20 studies, RR 0.60, 95% CI 0.40 to 90) representing a relative drop in the probability by 40% (95% CI 60% to 10%).Rates of recurrence of symptoms and the need for repeated surgery were comparable between ECTR and OCTR groups.The overall risk of bias in studies that contribute data to these results is rather high; fewer than 25% of the included studies had adequate allocation concealment, generation of allocation sequence or blinding of the outcome assessor.The quality of evidence in this review may be considered as generally low. Five of the studies were presented only as abstracts, with insufficient information to judge their risk of bias. In selection bias, attrition bias or other bias (baseline differences and financial conflict of interest) we could not reach a safe judgement regarding a high or low risk of bias. Blinding of participants is impossible due to the nature of interventions.We identified three further potentially eligible studies upon updating searches just prior to publication. These compared ECTR with OCTR (two studies) or mini-open carpal tunnel release (one study) and will be fully assessed when we update the review.

AUTHORS' CONCLUSIONS

In this review, with support from low quality evidence only, OCTR and ECTR for carpal tunnel release are about as effective as each other in relieving symptoms and improving functional status, although there may be a functionally significant benefit of ECTR over OCTR in improvement in grip strength. ECTR appears to be associated with fewer minor complications compared to OCTR, but we found no difference in the rates of major complications. Return to work is faster after endoscopic release, by eight days on average. Conclusions from this review are limited by the high risk of bias, statistical imprecision and inconsistency in the included studies.

A Retrospective Comparison of Conventional versus Transverse Mini-Incision Technique for Carpal Tunnel Release

Background. In this retrospective study, we aimed to compare the results of two surgical techniques, conventional and transverse mini-incision. Materials and Methods. 95 patients were operated between 2011 and 2012 in Bitlis State Hospital. 50 patients were operated with conventional technique and 45 of them were operated with minimal transverse incision. Postoperative complications, incision site problems, and the time of starting to use their hands in daily activities were noted. Results. 95 patients were included in the study. The mean age was 48. 87 of them were female and 8 were male. There was no problem of incision site in both of the two surgical techniques. Only in one patient, anesthesia developed in minimal incision technique. The time of starting to use their hands in daily activities was 22,2 days and 17 days in conventional and minimal incision technique, respectively. Conclusion. Two surgical techniques did not show superiority to each other in terms of postoperative complications and incision site problems except the time of starting to use their hands in daily activities.

Percutaneous ultrasound-guided MANOS carpal tunnel release technique

Ultrasound (US) is used with a minimally invasive cutting device to perform carpal tunnel release with a 3 mm wrist incision. US localizes tendons, arteries, and median nerve for safe introduction of the device into the wrist. The device is inserted in a blunt configuration under the flexor retinaculum, and a cutting wire is deployed that advances a 0.9-mm needle in the palm. The surgeon releases the flexor retinaculum from the inside out through the two skin punctures. Flexor retinaculum release is confirmed with US.

A double-blind randomized controlled trial showing the analgesic and anesthetic properties of lidocaine E to be equivalent to those of ropivicaine and bupivacaine in carpal tunnel release surgery

In a three-phase trial, the anesthetic properties of lidocaine, bupivacaine and ropivicaine were compared in carpal tunnel release surgery. In phase I, two groups of 25 sequential patients were injected with either lidocaine plain 2% or lidocaine 2% with adrenaline 1:100,000 (E), as the local anesthetic for outpatient carpal tunnel release surgery. Subjective injection pain, postoperative pain at 2 h increments and the number of analgesic pills taken were recorded. During the first postoperative hours, outcome measures were superior in the lidocaine E group. In phase II, a double-blind randomized design compared 42 patients injected with either lidocaine E or a combination of lidocaine E and bupivacaine. Postoperative pain scores and analgesic pills taken were compared using nonparametric statistical tests. During the first 4 h there was a slight benefit in the duration of the anesthetic and fewer pain pills were used in the bupivacaine group. Phase III was a randomized double-blind comparison of ropivicaine and lidocaine E 2% in 72 patients. There was a slight decrease in pain scores and fewer analgesic pills required during the first 6 h in the ropivicaine group. Lidocaine plain 2% provided significantly inferior analgesic and anesthetic properties compared with lidocaine E 2%, bupivacaine or ropivicaine. Sequential randomized comparisons between lidocaine E and bupivacaine and ropivicaine showed clinical equivalence. The present study showed lidocaine E 2% to be a satisfactory and comparatively cost-effective anesthetic for outpatient carpal tunnel surgery.

A methodological guide to performing a cost-utility study comparing surgical techniques

BACKGROUND

When recommending the adoption of a new surgical intervention as opposed to maintaining an old one, surgeons need to consider the opportunity cost, which is the value of the forgone benefits. To inform these decisions, surgeons can use economic analyses of surgical practices. Unfortunately, economic analyses conducted alongside randomized controlled trials in surgery are rare.

OBJECTIVES

The objective of the present study was to use data from a small randomized controlled trial to illustrate the methodology for a cost-utility analysis comparing two techniques of carpal tunnel release: open release without ('usual' technique) and with ('novel' technique) ligament reconstruction.

METHODS

Eighteen eligible patients were entered into this prospective study. Fifteen were followed to six weeks postoperatively. One day preoperatively, and five days, three weeks and six weeks postoperatively, patients completed a self-administered Health Utilities Index Mark 2-3 questionnaire (utilities) and a case report form from which resource utilization (cost) was collected. Utilities were expressed as quality-adjusted life weeks, a fraction of quality-adjusted life years.

RESULTS

The mean total cost of the usual technique was lower than the novel technique, and the mean quality-adjusted life week was higher, favouring the usual technique. Indirect costs were four to nine times higher than direct costs in both techniques.

CONCLUSION

The novel technique was more costly and less effective, and fell in the 'lose-lose' quadrant of the cost-effectiveness plane; it was rejected in favour of the usual technique. This methodology should be applied when deciding whether to adopt novel surgical techniques in plastic surgery to optimize scarce health care resources.

Clinical outcomes of endoscopic carpal tunnel release in patients 65 and over

PURPOSE

To examine outcomes of endoscopic carpal tunnel release (ECTR) in patients 65 and older. We hypothesized that this population could expect relief of pain, night pain/numbness, and numbness.

METHODS

A retrospective review was conducted of all patients 65 years of age and over who had ECTR for nerve conduction study-confirmed carpal tunnel syndrome (CTS) from October 2007 to July 2010. The charts were reviewed for demographic data, symptoms and physical findings, patient satisfaction, and 3 patient-reported outcome scores. Preoperative and postoperative results for pain, night pain/numbness, and numbness were compared. Logistic regression analysis was used to assess whether age influenced symptom resolution. Boston carpal tunnel, Short Form-36 and Disabilities of the Arm, Shoulder, and Hand scores were compared between patients with mild, moderate, or severe CTS.

RESULTS

A total of 78 patients had ECTR. Their ages ranged from 65 to 93 years (mean, 73 y). Before surgery 69% of patients had constant numbness. Night pain/numbness was present in 65 patients before surgery, and 61 had complete resolution. All 70 patients who presented with pain reported complete relief by the 6-month follow-up. Following ECTR, the average Boston carpal tunnel symptom severity, functional status, and Disabilities of the Arm, Shoulder, and Hand scores were 1.5,1.5, and 13, respectively. At final evaluation, 79% of patients were very satisfied or satisfied with their outcome. A significant number of patients were found to have improvement in pain, night pain/numbness, and numbness following ECTR.

CONCLUSIONS

This study has demonstrated relief of symptoms in a statistically significant number of patients following ECTR. We found that preoperative CTS severity, based on nerve conduction study result, did not significantly correlate with patient outcome following ECTR. Advanced symptoms at presentation do not preclude symptom resolution and should not be a contraindication to ECTR.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Carpal tunnel release: a randomized comparison of three surgical methods

A single-blind, randomized, controlled trial was done to compare the results of carpal tunnel release using classic incision, short incision, or endoscopic technique. In total, 90 consecutive cases were included. Follow-up was 24 weeks. We found a significantly shorter sick leave in the endoscopic group. No significant differences in pain, paraesthesiae, range of motion, pillar pain, and grip strength could be found at 24 weeks of follow-up, although intermediate significant differences were seen, especially in grip strength, in favour of endoscopic technique. No major advantage to using a short incision could be found. There were no serious complications in either group. The results indicate that the endoscopic procedure is safe and has the benefit of faster rehabilitation and return to work.