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

Evaluation of preoperative expectations and patient satisfaction after carpal tunnel release

PURPOSE

We tested the hypothesis that preoperative expectations affect postoperative satisfaction and arm-specific, self-reported health status after elective carpal tunnel release.

METHODS

Forty-nine patients having elective carpal tunnel release completed questionnaires evaluating self-rated upper extremity-specific disability using the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire, expectations regarding surgery (Preop Expectations Score), personal importance of upper-extremity function, measures of general optimism, the Life Orientation Test (LOT), as well as health-specific optimism, and the Multidimensional Health Locus of Control scale. Six months after surgery, patients completed a 10-point Likert scale to assess satisfaction, the DASH, and measures determining (1) fulfillment of expectations (Postop Met Expectations Score) and (2) relief of specific systems (Postop Help Score).

RESULTS

The DASH scores decreased significantly from an average of 37 points before surgery to an average of 15 points 6 months after carpal tunnel release (p<.001), and patients rated their satisfaction (mean +/- standard deviation) as 8 +/- 3. Preoperative expectations did not correlate with patient satisfaction or postoperative DASH scores. Multivariable analyses determined that patient satisfaction was best predicted by fulfillment of expectations (Postop Help Score alone, accounting for 41% of the variance in scores) and postoperative DASH scores were predicted by a combination of Postop Met Expectations Score and the LOT score (accounting for 31% of the variance in scores).

CONCLUSIONS

As measured in this study, the strongest predictor of satisfaction after carpal tunnel release was relief of symptoms, and the strongest predictors of postoperative disability were met expectations and optimism; however, the majority of the variance in postoperative satisfaction remains unexplained.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Effects of carpal tunnel release on the relative motion of tendon, nerve, and subsynovial connective tissue in a human cadaver model

BACKGROUND

The purpose of this study was to evaluate the effect of flexor retinaculum division (simulated carpal tunnel release) on the relative motion of flexor tendon, subsynovial connective tissue, and median nerve in human cadaver specimens.

METHODS

Using fluoroscopy, we measured the relative motion of middle finger flexor digitorum superficialis tendon, subsynovial connective tissue, and median nerve in twelve human cadavers with simulated fist motion. Measurements were obtained for three wrist positions: neutral; 60 degrees flexion; and 60 degrees extension. The shear index was defined as the difference in motion between two tissues (tendon, subsynovial connective tissue, or nerve) relative to tendon excursion, expressed as a percentage. After testing with an intact carpal tunnel, the flexor retinaculum was cut and the testing procedure was repeated.

FINDINGS

With an intact flexor retinaculum, the wrist flexion position showed significantly less displacement for the subsynovial connective tissue and median nerve relative to tendon displacement, and thus the highest potential shear strain between subsynovial connective tissue-tendon, and tendon-nerve. The wrist extension position also had a significantly higher potential shear strain for tendon-nerve compared to the neutral position. After division of the flexor retinaculum, the differences in shear index among wrist positions were reduced. For the wrist flexion position, the subsynovial connective tissue and median nerve displacements significantly increased, indicating lower shear index values.

INTERPRETATION

These findings suggest that division of flexor retinaculum reduces the potential shear strain and thus possibly the risk of shear injury to tissues with the carpal tunnel.

Median nerve excursion in response to wrist movement after endoscopic and open carpal tunnel release

PURPOSE

To compare the perioperative kinematic effects of endoscopic versus open carpal tunnel release on longitudinal excursion (gliding) and volar displacement (bowstringing) of the median nerve at the wrist region in patients with idiopathic primary carpal tunnel syndrome.

METHODS

Sixteen hands of 13 patients were randomly assigned into 2 groups (group 1, endoscopic; group 2, open carpal tunnel release). For the measurement of gliding and bowstringing of the median nerve, a metallic marker was used. Before and after the division of the transverse carpal ligament, longitudinal excursion and volar displacement of the median nerve were calculated based on fluoroscopic imaging for each wrist. Movement was analyzed for the measurement of the marker locations.

RESULTS

The mean prerelease median nerve excursion during wrist range of motion was 20 mm (range, 10-28) in group 1 and 21 mm (range, 16-31 mm) in group 2. The mean postrelease median nerve excursion during wrist range of motion was 20 mm (range, 13-29) in group 1 and 18 mm (range, 8-26 mm) in group 2. There was no statistically significant difference in pre- and postrelease longitudinal excursion changes between the groups (p = .916 and p = .674, respectively). The mean prerelease volar displacement of the median nerve during wrist range of motion was 3 mm in group 1 and 4 mm in group 2; the postrelease mean values were 2 mm and 5 mm, respectively. There was no statistically significant difference between the groups with regard to pre- and postrelease volar displacement changes of the median nerve (p = .372 and p = .103, respectively).

CONCLUSIONS

This study demonstrated that the endoscopic release and open carpal tunnel release produce similar perioperative effects on longitudinal and volar movements of the median nerve.

13-year experience of carpal tunnel release using the Indiana Tome technique

PURPOSE

This study evaluated the reliability and morbidity rate of carpal tunnel release with the Indiana Tome technique via a small palmar incision when used by experienced hand surgeons.

METHODS

A retrospective review was performed of 1332 carpal tunnel releases using the Indiana Tome performed by 2 fellowship-trained hand surgeons at university hospitals from July 1993 to August 2006. Chart review focused on complications with this technique.

RESULTS

All patients returned to preoperative activities, in employment or otherwise. Nonmanual laborers resumed regular job tasks between 2 days and 3 weeks. The 2 surgeons experienced 11 complications in 1332 cases, for an overall complication rate of 0.83%. The most common complication, in 8 cases, was numbness and hypersensitivity in the third common digital nerve distribution; 2 of these 8 patients had normal 2-point discrimination and the other 6 had persistently 2-point discrimination greater than 10 mm despite resolution of preoperative paresthesia symptoms. In the latter group, 3 patients had repeat exploration, with findings of fascicular injury and scarring in 2 patients and normal nerve in the third (who ultimately had normalized 2-point discrimination by 6 weeks after surgery). The 3 patients without re-exploration had their 2-point discrimination returned to normal by 11 months after surgery. Ultimately, only 2 patients (0.15%) had persistently increased 2-point discrimination. The remaining complications (3 cases) were transient neuropraxia of the entire median nerve (1 patient), an incomplete release (1 patient) requiring repeat surgery, and a recurrence of carpal tunnel syndrome (1 patient) with perineural scar noted at 8 months after surgery, treated successfully with a hypothenar fat pad flap.

CONCLUSIONS

This is the largest retrospective review of the Indiana Tome technique to date. This technique can be used by experienced hand surgeons and offers early resumption of preoperative activities and a low complication rate. The most common complication was neurapraxia in the third common digital nerve distribution. The overall complication rate was 0.83% (11 in 1332).

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Long-term outcome after carpal tunnel decompression - a prospective randomised study of the Indiana Tome and a standard limited palmar incision

This randomised trial compared the results of carpal tunnel decompression using the TM Indiana Tome (Biomet, Warsaw, Indiana, USA) and a standard limited palmar open incision. Two hundred patients were randomly selected to have a carpal tunnel decompression with either the Indiana Tome or a limited palmar technique. They were assessed clinically for 3 months and using the Levine-Katz self-assessment evaluation for 7 years. After 7 years, there were 62 returned questionnaires from the open group and 53 from the Tome group. There were no significant differences in functional scores, pain, scar tenderness, pinch and grip strength at 3 months. There were two complications in the open group and nine in the Tome group, including one median nerve injury. There was both a higher rate of immediate complications, and more recurrences and persisting symptoms at 7 years in the Indiana Tome group.

Carpal tunnel syndrome: matching minimally invasive surgical techniques

✓In the past few years, several different minimally invasive surgical techniques have been proposed to decompress the median nerve at the wrist. Use of these techniques has become widespread due to fewer local complications, faster functional recovery, and reduced surgical time. In this paper the authors compare 3 different minimally invasive surgical techniques used at their institution in the past 13 years. Between January 1994 and January 2007, 891 patients underwent 1272 surgeries at the authors' institution for carpal tunnel syndrome (CTS), for which a minimally invasive technique was used. In 473 cases (Group A), the transillumination technique with a single wrist incision and a “carpalotome” (a modified Paine retinaculotome) was used; in 216 cases (Group B), transillumination was abandoned and a single linear wrist incision for access with the carpalotome was performed; and in 583 cases (Group C), the techniques were further modified by making a second incision in the palm using the carpalotome. All 3 groups of patients were homogeneous for age, sex, and duration of the symptomatology. In 90% of the patients in Group A, in 88% of those in Group B, and 99.8% of patients in Group C, complete remission of symptoms was obtained. Due to persistence of symptoms, 44 patients in Group A, 24 in Group B, and only 1 in Group C underwent a repeated operation with the open technique. The only surgical complication requiring repeated operation of the 1272 operations was a lesion of the primitive median artery (1 patient in Group C).

The technique of median nerve decompression at the wrist that was used for patients in Group C represents a valid alternative for treatment of CTS.

Anatomical landmarks to the superficial and deep palmar arches

BACKGROUND

Knowledge of the relationship of the palmar arches to anatomical landmarks would decrease iatrogenic injuries, facilitate treatment of vascular occlusive disease, and ease interpretation of abnormal arteriograms. The purpose of this study was to identify the location of the palmar arches in relation to surface and bony landmarks.

METHODS

The palmar arches in 48 cadavers were identified through dissection. The most distal points of the palmar arches were measured in relation to Kaplan's cardinal line, the distal wrist crease, and the carpometacarpal joint of the ring finger. The distances of the palmar arches to the radiocarpal joint were measured on 30 arteriograms.

RESULTS

The superficial palmar arch and deep palmar arch were found to be on average 15.3 +/- 8.60 mm and 6.70 +/- 4.82 mm distal to Kaplan's cardinal line, respectively. The superficial palmar arch was found to be on average 51.8 +/- 7.56 mm distal to the distal wrist crease, while the deep palmar arch was only 40.1 +/- 7.92 mm from the distal wrist crease. The average distances from the superficial palmar arch and deep palmar arch to the carpometacarpal joint of the ring finger were 32.2 +/- 6.33 mm and 18.3 +/- 4.64 mm, respectively. On arteriography, the superficial palmar arch and deep palmar arch were on average 50.3 +/- 8.61 mm and 44.89 +/- 4.77 mm, respectively, from the radiocarpal joint.

CONCLUSIONS

The superficial and deep palmar arches were located at consistent distances from easily identifiable surface and bony landmarks. Knowledge of these predictable anatomical relations would aid clinicians in surgical dissection, treatment of vascular occlusive disease, and interpretation of abnormal arteriograms when only one arch is present.

The Japanese experience with endoscopic carpal tunnel release

Endoscopic carpal tunnel release (ECTR) is generally touted to be a less invasive operation that offers the advantages of less postoperative pain and an earlier return to work compared with conventional open carpal tunnel release (OCTR). ETCR, however, does require special new skills that preferably should be acquired by practice on cadavers before clinical use. Because access to fresh cadavers is restricted in Japan, here we have to gain this experience in actual clinical cases with the assistance of another surgeon who is familiar with the technique. In contradistinction, a "mini" open technique can be learned stepwise just by shortening the conventional incision of OCTR during one's own clinical experience. Because reimbursement for ECTR was recently raised to be 1.5 times that for OCTR in Japan, that factor alone might make ECTR more popular in a few years. However, at least for the present, the mini open technique is still less costly without the associated risks of complications inherent with ETCR and has proved for the time being to be more suitable for the current medical climate in Japan.

Study to assess differences in outcome following open carpal tunnel decompressions performed by surgeons of differing grade

INTRODUCTION

Carpal tunnel decompression is the most commonly performed surgical procedure within a hand unit. Although very effective, the complications following the procedure can be significant. In an attempt to identify the causes of such complications, we assessed whether seniority of the surgeon impacts on outcome for open carpal tunnel decompression.

PATIENTS AND METHODS

Data were jointly and prospectively gathered from two units from either side of the Atlantic - the Pulvertaft Hand Center, UK and the Curtis Hand Center, USA. The aim of the study was to assess outcome following carpal tunnel decompression. Completed data were gathered following open carpal tunnel decompression on 352 hands. Surgeons of a consultant grade had performed 123 of these procedures whilst surgical trainees had performed 229 of the procedures. Assessment was by Levine Katz questionnaire results, Semmes-Weinstein testing, grip strength and pinch grip strength testing performed both pre-operatively and 6 months' postoperatively. Complications following the procedure were also recorded.

RESULTS

Mean results were found to be better in those patients where the surgeon was of a consultant grade. However, this was only found to be of statistical significance on Semmes-Weinstein testing. Complications following the procedure were also noted to be higher in the group of patients operated on by trainee grades.

CONCLUSIONS

Our results show the carpal tunnel decompression performed by a surgeon of consultant grade offers slightly better results in objective neurological testing when compared with those performed by a more junior grade.

Power grip, pinch grip, manual muscle testing or thenar atrophy - which should be assessed as a motor outcome after carpal tunnel decompression? A systematic review

Background

Objective assessment of motor function is frequently used to evaluate outcome after surgical treatment of carpal tunnel syndrome (CTS). However a range of outcome measures are used and there appears to be no consensus on which measure of motor function effectively captures change. The purpose of this systematic review was to identify the methods used to assess motor function in randomized controlled trials of surgical interventions for CTS. A secondary aim was to evaluate which instruments reflect clinical change and are psychometrically robust.

Methods

The bibliographic databases Medline, AMED and CINAHL were searched for randomized controlled trials of surgical interventions for CTS. Data on instruments used, methods of assessment and results of tests of motor function was extracted by two independent reviewers.

Results

Twenty-two studies were retrieved which included performance based assessments of motor function. Nineteen studies assessed power grip dynamometry, fourteen studies used both power and pinch grip dynamometry, eight used manual muscle testing and five assessed the presence or absence of thenar atrophy. Several studies used multiple tests of motor function. Two studies included both power and pinch strength and reported descriptive statistics enabling calculation of effect sizes to compare the relative responsiveness of grip and pinch strength within study samples. The study findings suggest that tip pinch is more responsive than lateral pinch or power grip up to 12 weeks following surgery for CTS.

Conclusion

Although used most frequently and known to be reliable, power and key pinch dynamometry are not the most valid or responsive tools for assessing motor outcome up to 12 weeks following surgery for CTS. Tip pinch dynamometry more specifically targets the thenar musculature and appears to be more responsive. Manual muscle testing, which in theory is most specific to the thenar musculature, may be more sensitive if assessed using a hand held dynamometer – the Rotterdam Intrinsic Handheld Myometer. However further research is needed to evaluate its reliability and responsiveness and establish the most efficient and psychometrically robust method of evaluating motor function following surgery for CTS.

Surgical treatment options for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome is a common disorder for which several surgical treatment options are available.

OBJECTIVES

To compare the efficacy of the various surgical techniques in relieving symptoms and promoting return to work or activities of daily living and to compare the occurrence of side-effects and complications in patients suffering from carpal tunnel syndrome.

SEARCH STRATEGY

We updated the searches in 2006. We conducted computer-aided searches of the Cochrane Neuromuscular Disease Group Trials Register (searched in June 2006), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 2), MEDLINE (January 1966 to June 2006), EMBASE (January 1980 to June 2006) and also tracked references in bibliographies.

SELECTION CRITERIA

Randomised controlled trials comparing various surgical techniques for the treatment of carpal tunnel syndrome.

DATA COLLECTION AND ANALYSIS

Two review authors performed study selection, assessment of methodological quality and data extraction independently of each other.

MAIN RESULTS

Thirty-three studies were included in the review of which 10 were newly identified in this update. The methodological quality of the trials ranged from fair to good; however, the use of allocation concealment was mentioned explicitly in only seven trials. Many studies failed to present the results in sufficient detail to enable statistical pooling. Pooling was also impeded by the vast variety of outcome measures that were applied in the various studies. None of the existing alternatives to standard open carpal tunnel release offered significantly better relief from symptoms in the short- or long-term. In three studies with a total of 294 participants, endoscopic carpal tunnel release resulted in earlier return to work or activities of daily living than open carpal tunnel release, with a weighted mean difference of -6 days (95% CI -9 to -3 days).

AUTHORS' CONCLUSIONS

There is no strong evidence supporting the need for replacement of standard open carpal tunnel release by existing alternative surgical procedures for the treatment of carpal tunnel syndrome. The decision to apply endoscopic carpal tunnel release instead of open carpal tunnel release seems to be guided by the surgeon's and patient's preferences.

Carpal tunnel syndrome

Carpal tunnel syndrome is the most common compressive neuropathy of the upper extremity. As a result of median nerve compression, the patient reports pain, weakness, and paresthesias in the hand and digits. The etiology of this condition is multifactorial; anatomic, systemic, and occupational factors have all been implicated. The diagnosis is based on the patient history and physical examination and is confirmed by electrodiagnostic testing. Treatment methods range from observation and splinting, to cortisone injection and splinting, to surgical intervention. Both nonsurgical and surgical management provide symptom relief in most patients. The results of open and endoscopic surgery essentially are equivalent at 3 months; the superiority of one technique over the other has yet to be established.

Minimally invasive carpal tunnel decompression using the KnifeLight

OBJECTIVES

Carpal tunnel syndrome is a common condition causing hand pain, dysfunction, and paresthesia. Endoscopic carpal tunnel decompression offers many advantages compared with conventional open surgical decompression. However, it is equipment intensive and requires familiarity with endoscopic surgery. We review a minimally invasive technique to divide the flexor retinaculum by using a new instrument, the KnifeLight (Stryker, Kalamazoo, Michigan), which combines the advantages of the open and endoscopic methods, without the need for endoscopic set-up.

METHODS

Between July 2003 and April 2005, 44 consecutive patients (26 women [59%] and 18 men [36%]), with clinical signs and symptoms, as well as electrodiagnostic findings consistent with carpal tunnel syndrome, who did not respond to non-surgical treatment, underwent the new procedure. All patients were asked about scar hypertrophy, scar tenderness, and pillar pain. The Michigan Hand Outcomes Questionnaire (MHQ) was used to determine overall hand function, activities of daily living, work performance, pain, aesthetics, and satisfaction with hand function. Other preoperative testing included grip strength and lateral pinch strength. Grip strength was measured using the Jamar hand dynamometer (Asimov Engineering Co., Los Angeles, CA); lateral key pinch was measured using the Jamar hydraulic pinch gauge. Postoperative evaluations were scheduled at 2 weeks, 3 months, and 6 months after the procedure. A small 10-mm incision was made in the wrist crease and a small opening was made at the transverse carpal ligament. The KnifeLight tool was inserted, and the ligament was incised completely. Follow-up evaluations with use of quantitative measurements of grip strength, pinch strength, and hand dexterity were performed at 2 weeks, 3 months, and 6 months after surgery.

RESULTS

Fifty procedures were performed on 22 left hands (44%) and 28 right hands (56%). There were no complications related to the approach. All patients were able to use their hands immediately after the surgery. Scar tenderness and incisional pain were mild-to-moderate in the first 2 weeks, and these symptoms disappeared completely 6 months after surgery. Significant postoperative improvements in pain relief, patient satisfaction, hand function, daily activities, and work performance as assessed with the MHQ were noted at 3 and 6 months after surgery. Furthermore, significant improvement in patients' hand grip and pinch strength were observed 6 months after surgery. From a literature review, we found that the mean operation time of KnifeLight carpal tunnel release was the shortest compared with the conventional and endoscopic carpal tunnel release techniques. The median time needed for our patients to return to work was also the shortest among the different techniques.

CONCLUSION

Excellent functional outcomes and satisfaction were achieved using the KnifeLight for carpal tunnel decompression. Our minimally invasive method offers a quick, easy, and effective alternative to conventional or endoscopic carpal tunnel decompression.

Repetitive strain injury

Repetitive strain injury remains a controversial topic. The term repetitive strain injury includes specific disorders such as carpal tunnel syndrome, cubital tunnel syndrome, Guyon canal syndrome, lateral epicondylitis, and tendonitis of the wrist or hand. The diagnosis is usually made on the basis of history and clinical examination. Large high-quality studies using newer imaging techniques, such as MRI and ultrasonography are few. Consequently, the role of such imaging in diagnosis of upper limb disorders remains unclear. In many cases, no specific diagnosis can be established and complaints are labelled as non-specific. Little is known about the effectiveness of treatment options for upper limb disorders. Strong evidence for any intervention is scarce and the effect, if any, is mainly short-term pain relief. Exercise is beneficial for non-specific upper limb disorders. Immobilising hand braces and open carpal tunnel surgery release are beneficial for carpal tunnel syndrome, and topical and oral non-steroidal anti-inflammatory drugs, and corticosteroid injections are helpful for lateral epicondylitis. Exercise is probably beneficial for neck pain, as are corticosteroid injections and exercise for shoulder pain. Although upper limb disorders occur frequently in the working population, most trials have not exclusively included a working population or assessed effects on work-related outcomes. Further high-quality trials should aim to include sufficient sample sizes, working populations, and work-related outcomes.

Use of Sonography in Carpal Tunnel Syndrome Surgery-A Prospective Study-

The diagnosis of carpal tunnel syndrome (CTS) is mainly based on the characteristic symptoms and confirmed with nerve conduction studies. Sonography can provide measurements of the increased cross-sectional area of median nerve. The use of sonography was evaluated for the diagnosis and postoperative follow up of 48 wrists in 26 consecutive patients with CTS. Clinical evaluation and sonography were effective for the diagnosis in 40 wrists. Nerve conduction studies were needed in eight wrists, because of the decrease in cross-sectional area of the nerve as a result of degenerative changes. After 3 months, sonography detected statistically significant decreases in the cross-sectional areas of the median nerves. The sonographic studies were well tolerated by all patients. Sonography was both time-saving and cost-effective.

Endoscopic versus open carpal tunnel release: A short-term comparative study

OBJECTIVE

To compare the results of endoscopic carpal tunnel release (CTR) with open CTR in patients with idiopathic Carpal tunnel syndrome (CTS).

MATERIALS AND METHODS

Seventy-one patients with CTS were enrolled in a prospective randomized study from May 2003 to December 2005. All patients had clinical signs or symptoms and electro-diagnostic findings consistent with carpal tunnel syndrome and had not responded to nonoperative management. Sixty-one cases were available for follow-up. Endoscopic CTR was performed in 30 CTS patients and open CTR was performed in 31 wrists (30 patients). Various parameters were evaluated, including each patient's symptom amelioration, complications, operation time, time needed to resume normal lifestyle and the frequency of revision surgery. All the patients were followed up for six months.

RESULTS

During the initial months after surgery, the patients treated with the endoscopic method were better symptomatically and functionally. Local wound problems in terms of scarring or scar tenderness were significantly more pronounced in patients undergoing open CTR compared to patients undergoing endoscopic CTR. Average delay to return to normal activity was appreciably less in group undergoing endoscopic CTR. No significant difference was observed between the endoscopic CTR group and open CTR group in regard to symptom amelioration, electromyographic testing and complications at the end of six months.

CONCLUSION

Short-term results were better with the endoscopic method as there was no scar tenderness. Results at six months were comparable in both groups.

A systematic review of outcomes assessed in randomized controlled trials of surgical interventions for carpal tunnel syndrome using the International Classification of Functioning, Disability and Health (ICF) as a reference tool

BACKGROUND

A wide range of outcomes have been assessed in trials of interventions for carpal tunnel syndrome (CTS), however there appears to be little consensus on what constitutes the most relevant outcomes. The purpose of this systematic review was to identify the outcomes assessed in randomized clinical trials of surgical interventions for CTS and to compare these to the concepts contained in the International Classification of Functioning, Disability and Health (ICF).

METHODS

The bibliographic databases Medline, AMED and CINAHL were searched for randomized controlled trials of surgical treatment for CTS. The outcomes assessed in these trials were identified, classified and linked to the different domains of the ICF.

RESULTS

Twenty-eight studies were retrieved which met the inclusion criteria. The most frequently assessed outcomes were self-reported symptom resolution, grip or pinch strength and return to work. The majority of outcome measures employed assessed impairment of body function and body structure and a small number of studies used measures of activity and participation.

CONCLUSION

The ICF provides a useful framework for identifying the concepts contained in outcome measures employed to date in trials of surgical intervention for CTS and may help in the selection of the most appropriate domains to be assessed, especially where studies are designed to capture the impact of the intervention at individual and societal level. Comparison of results from different studies and meta-analysis would be facilitated through the use of a core set of standardised outcome measures which cross all domains of the ICF. Further work on developing consensus on such a core set is needed.

Standard open decompression in carpal tunnel syndrome compared with a modified open technique preserving the superficial skin nerves: a prospective randomized study

PURPOSE

A common surgical treatment for carpal tunnel syndrome is open carpal tunnel decompression. This involves skin incision followed by sharp dissection straight down through fat and palmar fascia to the transverse carpal ligament, which is then divided. The incidence of scar discomfort ranges from 19% to 61%, and its cause is not fully understood. We conducted a prospective randomized controlled trial to investigate whether preservation of superficial nerve branches crossing the incision site reduces the incidence and severity of postoperative scar pain after open carpal tunnel release.

METHODS

Forty-two patients with bilateral idiopathic carpal tunnel syndrome (84 hands) were included in the study. The patients were randomized to determine which hand was to have carpal tunnel decompression using a technique that would try to preserve the superficial nerve branches. The other hand had open carpal tunnel decompression without any attempt to preserve the superficial nerve branches. An assessment of each hand in each patient was performed immediately before surgery and at 6 weeks, 3 months, and 6 months after surgery. This assessment was performed with a questionnaire based on the Patient Evaluation Measure.

RESULTS

We found no evidence of a difference in scar pain between the 2 methods at 6 weeks, 3 months, and 6 months. There was a significant difference in the length of surgery between the 2 groups.

CONCLUSIONS

Scar pain scores in this series of open carpal tunnel decompressions were similar, whether or not an attempt was made to identify and preserve superficial nerve branches crossing the wound.

Comparison of splinting, splinting plus local steroid injection and open carpal tunnel release outcomes in idiopathic carpal tunnel syndrome

The objective of this study was to compare the short- and long-term efficacies of splinting (S), splinting plus local steroid injection (SLSI), and open carpal tunnel release (OCTR) in mild or moderate idiopathic carpal tunnel syndrome (CTS). Patients with mild or moderate idiopathic CTS who experienced symptoms for over 6 months were included in the study. The patients were evaluated for the baseline and the third and sixth month scores after treatment. Follow-up criteria were ENMG parameters, Boston Questionnaire, and patient satisfaction. Fifty-seven hands completed the study. Twenty-three hands had been splinted for 3 months. Twenty-three hands were given a single steroid injection and splinted for 3 months, and 11 hands were operated. In the first 3 months, all treatment methods provided significant improvements in both clinical and EMG parameters in which OCTR had better outcomes on median sensorial nerve velocity at palm wrist segment. In the second 3 months, while the clinical and EMG parameters began to deteriorate in S and SLSI group, OCTR group continued to improve, and BQ functional capacity score of OCTR group was statistically better than that in conservative methods (P = 0.03). S and SLSI treatments improved clinical and EMG parameters comparable to OCTR in short term. However, these beneficial effects were transient in the sixth month follow-up and OCTR was superior to conservative treatments.

Kaplan's cardinal line

PURPOSE

To determine if a consensus definition exists in the literature and among hand surgeons for Kaplan's cardinal line (KCL) and to determine the relationship of the various descriptions to deep structures.

METHODS

The literature contains 4 different descriptions of KCL. Members of the American Society for Surgery of the Hand were surveyed to determine which line they understand to be the correct description of KCL. The 4 variations of KCL were marked on cadavers and the lines' precision in identifying deep structures was measured.

RESULTS

Our survey showed that there is no consensus regarding the definition of KCL. Fifty percent of the surgeons surveyed use KCL as a surgical landmark. A line extended along the abducted thumb and a line from the apex of the interdigital fold between the thumb and the index finger to the hook of hamate most closely reproduce the location of deep structures of the hand and are the farthest from and always proximal to the superficial palmar arch. The line from the apex of the interdigital fold between the thumb and the index finger parallel to the middle crease of the palm and the line from the apex of the interdigital fold between the thumb and the index finger to a point 2 cm distal to the pisiform are the farthest from the motor branch of the median nerve and are markedly closer to the superficial palmar arch. All lines are radial and distal to the motor branch of the median nerve.

CONCLUSIONS

Ambiguity exists regarding the definition of KCL among hand surgeons and in the literature. Although no single line is ideal for locating all deep structures, line C is the safest line to identify hand anatomy. Kaplan's cardinal line does not locate the deep structures of the hand accurately but may assist in making palmar incisions.

A Novel Endoscopic Technique in Treating Single Nerve Entrapment Syndromes with Special Attention to Ulnar Nerve Transposition and Tarsal Tunnel Release: Clinical Application

OBJECTIVE:

To describe a simple retractor integrated endoscopic technique for treating idiopathic solitary compression neuropathies with special attention to the anterior transposition of the ulnar nerve and tarsal tunnel release, and to present the clinical results.

METHODS:

Eleven patients with ulnar sulcus syndrome, eight with tarsal tunnel syndrome, and one with meralgia paraesthetica (seven females and 13 males; age range, 12–64 yr) were treated with endoscopic anterior ulnar nerve transposition and in situ decompression of the tibial (eight patients) and lateral femoral cutaneous nerves (one patient), respectively. The selection criteria were: classical nerve compression symptoms, failed conservative treatment, abnormal electrophysiology, and a nonviolated anatomic region. The degree of nerve compression (after Dellon) was rated as moderate in five out of 20 patients and as severe in 15 out of 20 patients. Electrophysiological studies were conducted independently by physicians specializing in these techniques. Postoperative recovery was evaluated according to the nine-point Bishop rating system.

RESULTS:

Of the 11 patients with anterior ulnar nerve transposition, seven scored excellent, three scored good, and one scored fair (mean follow-up, 15.5 mo; range, 6–27 mo). Five patients with tarsal tunnel release scored excellent and three scored good (mean follow-up, 10.1 mo; range, 3–24 mo). The patient with meralgia paraesthetica showed an excellent score at 28 months after surgery. There were no technical or postoperative complications. None of the operations had to be converted to open surgery.

CONCLUSION:

We describe a new endoscopic technique for transposing the ulnar nerve and decompressing the tibial nerve. This technique could be extrapolated to release other single nerve entrapments. The simplicity of the technique, and our preliminary clinical results, may encourage other groups to adapt this method.

Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial

OBJECTIVES

To compare endoscopic and open carpal tunnel release surgery among employed patients with carpal tunnel syndrome.

DESIGN AND SETTING

Randomised controlled trial at a single orthopaedic department.

PARTICIPANTS

128 employed patients aged 25-60 years with clinically diagnosed and electrophysiologically confirmed idiopathic carpal tunnel syndrome.

MAIN OUTCOME MEASURES

The primary outcome was severity of postoperative pain in the scar or proximal palm and the degree to which pain or tenderness limits activities, each rated on a 4 point scale, transformed into a combined score of 0 (none) to 100 (severe pain or tenderness causing severe activity limitation). The secondary outcomes were length of postoperative work absence, severity of symptoms of carpal tunnel syndrome and functional status scores, SF-12 quality of life score, and hand sensation and strength (blinded examiner); follow-up at three and six weeks and three and 12 months.

RESULTS

63 patients were allocated to endoscopic surgery and 65 patients to open surgery, with no withdrawals or dropouts. Pain in the scar or proximal palm was less prevalent or severe after endoscopic surgery than after open surgery but the differences were generally small. At three months, pain in the scar or palm was reported by 33 patients (52%) in the endoscopic group and 53 patients (82%) in the open group (number needed to treat 3.4, 95% confidence interval 2.3 to 7.7) and the mean score difference for severity of pain in scar or palm and limitation of activity was 13.3 (5.3 to 21.3). No differences between the groups were found in the other outcomes. The median length of work absence after surgery was 28 days in both groups. Quality of life measures improved substantially.

CONCLUSIONS

In carpal tunnel syndrome, endoscopic surgery was associated with less postoperative pain than open surgery, but the small size of the benefit and similarity in other outcomes make its cost effectiveness uncertain.

Current status of outcomes research in carpal tunnel surgery

More than 3,000 publications on carpal tunnel syndrome (CTS) have been presented in the literature. Although surgery for treating CTS is commonly performed, the outcomes of these surgical procedures are still relatively unclear. This paper will summarize relevant publications on the surgical treatment of CTS to critically examine outcomes data based on the best available evidence.

The thenar index: an objective assessment and classification of thenar atrophy based on static hand imprints and clinical implications

BACKGROUND

The aims of this study were to test the effectiveness of the subjective clinical evaluation and to search for any possibility of constituting an objective assessment system for the diagnosis of thenar atrophy based on static hand imprints.

METHODS

Static hand imprints were obtained from normal subjects (group A, n = 116) and carpal tunnel syndrome patients with thenar atrophy (group B, n = 26). Thenar index and the bilateral thenar index ratio were defined. Cutoff values were considered by analyses with receiver operating characteristic curves.

RESULTS

No statistically significant difference could be demonstrated in thenar index values of dominant and nondominant hands between genders and age groups (p > 0.05). A statistically significant difference was observed between severity groups in group B (p < 0.05). There was a statistically significant difference between thenar index and bilateral thenar index ratio values of groups A and B (p < 0.05). Cutoff values were considered a thenar index of 31 and a bilateral thenar index ratio of 0.8, which revealed acceptable specificity (95.3 percent) and sensitivity (77.4 percent). A new quantitative classification for thenar atrophy severity is proposed.

CONCLUSIONS

Understanding the true onset and natural progression of thenar atrophy can only be anticipated with the aid of an objective assessment system. Currently, this method should be regarded as a system for patient records and comparison for presurgical and postsurgical data. The authors believe that the thenar index classification has some merit for future use. It seems that additional objective and scientific evaluation systems and novel approaches are still needed to demystify the true nature of carpal tunnel syndrome.

Carpal tunnel release through a small incision using a special knife guide

There have been controversial opinions regarding whether the release of the carpal tunnel should be performed arthroscopically or through an open incision. The authors present a method of open release through a small incision using a set of specially designed instruments, retaining advantages of observing the pathology under direct vision and avoiding complications of hazardous injuries to important structures. The instruments consist of a thin metal guide with a groove in the center to accommodate an angled knife holder. The procedure has been performed since 1997 with no complications.

Endoscopic carpal tunnel release: a review of 753 cases in 486 patients

BACKGROUND

Endoscopic carpal tunnel release is gaining increasing acceptance relative to the standard open carpal tunnel release for the treatment of carpal tunnel syndrome. Concerns about endoscopic carpal tunnel release include effectiveness of therapy and complication rates. This study attempted to evaluate outcomes of endoscopic carpal tunnel release in a large patient cohort.

METHODS

Four hundred eighty-six patients (753 hands) with carpal tunnel syndrome who underwent endoscopic carpal tunnel release by a single surgeon were reviewed retrospectively. Data included demographics, subjective complaints, prior interventions, preoperative examination findings, and postoperative follow-up. All follow-up data were obtained from a single, independent, occupational therapy clinic.

RESULTS

Median patient age was 48 years. Three hundred seventy-seven patients were gainfully employed at presentation, and 206 filed a worker's compensation claim. Median symptom duration was 2 years. Nonoperative therapy was ineffective in 151 patients. Preoperative nerve conduction studies were consistent with carpal tunnel syndrome in 472 patients (97 percent); all patients had either physical examination findings or nerve conduction studies consistent with carpal tunnel syndrome. Four hundred eighty-six patients (100 percent) obtained symptom relief. Complications included one transient median nerve neurapraxia, six complaints of residual pain, and one complaint of hypersensitivity. Worker's compensation patients and non-worker's compensation patients returned to work full-duty at similar times postoperatively. Ninety percent of employed patients returned to their original occupation.

CONCLUSIONS

The authors' data indicate that an endoscopic approach for the treatment of carpal tunnel syndrome is safe and effective. Patients demonstrated a high return-to-work rate and an extremely low complication rate. The data challenge the belief that endoscopic carpal tunnel release results in higher complication rates.

Carpal tunnel syndrome: comparison of intraoperative structural changes with clinical and electrodiagnostic severity

The aim of this study is to grade the intraoperative findings seen in carpal tunnel syndrome (CTS) based on severity, and compare it with clinical and electrodiagnostic severity. Thirty-one hands surgically treated for CTS were graded according to the severity of clinical signs, and electrodiagnostic tests. Oedema, vascularisation, and fibrosis were graded on a scale of 1-3. Pseudoneuroma or 'hour-glass' formation were graded as either 0 or 1. The hands were allocated by an observer into an assumptive severity group, from grade 1 to 3. Clinical severity and electrodiagnostic severity were statistically compared with each other, and with each intraoperative severity criteria. A high statistical correlation (p < 0.01) was found between clinical severity and vascularisation, fibrosis, and the assumptive intraoperative severity. No correlation could be demonstrated between electrodiagnostic severity and the intraoperative criteria. Intraoperative grading should be regarded as a supportive measure to the clinical evaluation in order to obtain a sound base for surgical intervention and internal neurolysis.

Challenges in Creating a Good Randomized Controlled Trial in Hand Surgery

The goal of this article is to inform readers of hand surgery literature and, more importantly, investigators about key design issues in randomized trials in hand surgery. Specifically, it describes the application of the Consolidated Standards of Reporting Trials in hand surgery trials and provides tips for reading the hand surgery literature. Unique challenges in the execution of a randomized controlled trial in hand surgery are explained, including the surgical learning curve, randomization, concealment and blinding, loss to follow-up, intention to treat analysis, surgical equipoise, differential care, and treatment effect and its implications for sample size. Additionally, the relevance of incorporating economic analyses into hand surgery trials and the importance of changing the hand surgeons' research culture are addressed.

Endoscopic carpal tunnel release surgery: retrospective study of 390 consecutive cases

Endoscopic carpal tunnel release (ECTR) surgery was developed by Okutsu and Chow in 1989. Many reports indicated that the endoscopic technique reduces postoperative morbidity with minimal incision, minimal pain and scarring, a shortened recovery period and high level of patient satisfaction. To evaluate these reports, a retrospective study was conducted with 390 procedures of two-portal Chow technique for idiopathic carpal tunnel syndrome. Follow-up was performed at 1, 3 and 6 months and overall results were backed up by telephone questionnaire (Health Outcomes Carpal Tunnel Questionnaire, Health Outcomes, Bloomington, MN, USA). Results were favourable in 98% and 2% unfavorable for persistent pain. Rate of satisfaction of the patients was 90%. Average time of patient's return to work was 20 days. Eleven procedures (2.8%) were converted to open release. There was one case (0.2%) of incompleted section of the perineurium due to failure of endoscopic visualization of the ligament. In this case the procedure was converted to open and was completed with perineurium sutura. In six cases (1.5%) there were injury to superficial palmar arch. During the follow-up period there were no recurrences and no re-exploration. The mean preoperatively obtainable distal motor latency (DML) and sensory conduction velocity (SCV) values were 6.7 m/s and 29.2 m/s, respectively. The mean DML and SVC values at final follow-up were 3.8 msec and 42.3 m/s, respectively. In conclusion, ECTR can be used in the carpal tunnel syndrome and is a reliable alternative to the open procedure with excellent self-report of patient satisfaction. Reduced recovery period with minimal tissue violation and incisional pain can be expected.

Mini-open blind procedure versus limited open technique for carpal tunnel release: a 30-month follow-up study

PURPOSE

To evaluate prospectively the safety and effectiveness of a mini-open blind technique for carpal tunnel release (group A) when compared with a limited open technique (group B).

METHODS

From November 1999 to May 2001 (mean follow-up period, 30 mo) we performed 222 carpal tunnel release procedures on 185 consecutive patients. All patients were affected by mild to moderate median nerve compression. Patients in group A (82 patients, 99 procedures) had a short transverse incision at the wrist (length, 2 cm). We used a manual surgical instrument that helps in blindly dividing the flexor retinaculum because it has an integrated light source. The light makes it possible to locate precisely the tool blade by transillumination. Patients in group B (103 patients, 123 procedures) had a limited longitudinal incision (length, 3-4 cm). The preoperative and postoperative patient statuses were evaluated with an Italian modified version of the Boston Carpal Tunnel questionnaire with a mean of 30 months' follow-up after surgery (range, 24-39 mo).

RESULTS

Group A patients showed better results than group B patients in all of the sections of the Italian modified version of the Boston Carpal Tunnel questionnaire at a mean follow-up period of 19 months, whereas after a mean of 30 months of follow-up evaluation the differences between groups A and B tended to decrease. Disease recurred in 7 group B patients, whereas only 1 patient in group A experienced symptom recurrence at the latest office evaluation.

CONCLUSIONS

The blind mini-invasive technique has been shown to be as safe as traditional techniques but the recovery period is significantly shortened. With the technique we described a low recurrence rate was observed. All patients in group A reported great reduction in preoperative pain and numbness.

Complex surgical conditions of the hand: avoiding the pitfalls

Many factors can contribute to a successful result in hand surgery, as is the case in all orthopaedic surgery. An accurate diagnosis with emphasis on a complete history coupled with a detailed physical examination supplemented with the appropriate ancillary studies and proper preoperative surgical planning all are necessary in reaching this goal. An improper diagnosis such as in suspected carpal tunnel syndrome can result in continued symptoms. We will emphasize some of the more complex and difficult conditions in hand surgery that necessitate a high level of clinical acumen. It is hoped that by highlighting these details we may help others avoid common pitfalls and help to achieve an excellent result and avoid litigation. Although these are not the only problems involved in hand surgery, they are complex and can be missed easily.

Analysis of reporting return to work in studies comparing open with endoscopic carpal tunnel release: A review of randomized controlled trials

BACKGROUND

In studies comparing open with endoscopic carpal tunnel release, return to work (RTW) is often cited as a primary outcome.

OBJECTIVE

The present study assessed the reporting of RTW and evaluated its usefulness in studies comparing these two methods of carpal tunnel release.

METHODS

A computerized search was conducted to find randomized controlled trials that compared open with endoscopic carpal tunnel release, with RTW as an outcome measure. The factors that were compared across the studies included definition of RTW, units quantifying RTW, measures of hand function, patients' type of employment, worker's compensation or insurance status, patients' handedness, unilateral or bilateral carpal tunnel release, and use of rehabilitation.

RESULTS

Fifteen studies met the inclusion criteria for the present systematic review. Of the 15 studies reviewed, there were seven definitions of RTW. All studies defined whether the patients underwent unilateral or bilateral carpal tunnel release but there was variability in the calculation of RTW when bilateral releases were performed. The impact of worker's compensation or insurance, type of work, handedness and rehabilitation were inconsistently addressed as factors affecting RTW.

CONCLUSIONS

Although RTW ideally reflects function and recovery, it is inadequately measured and reported. The present review revealed that, in studies comparing open carpal tunnel release with endoscopic carpal tunnel release, there is lack of uniformity in reporting RTW, which may contribute to the inconclusive results for RTW. Future research needs to ensure that RTW is used in a consistent manner.

Reavaliação a longo prazo do tratamento cirúrgico da síndrome do túnel do carpo por incisão palmar e utilização do instrumento de Paine®

A síndrome do túnel do carpo (STC) é a síndrome compressiva mais comum e a cirurgia de liberação do retináculo dos flexores uma das mais realizadas no mundo. Desde a via aberta clássica, mini-incisões até a endoscópica, o sucesso obtido com a cirurgia a curto prazo está bem estabelecido, porém os estudos a longo prazo ainda são escassos e avaliam, principalmente, sinais clínicos e sintomas. O objetivo deste estudo é avaliar os pacientes tratados pela incisão palmar e utilização do instrumento de Paine® com no mínimo seis anos de pós-operatório (98 meses em média). Foram feitas avaliações pré e pós-operatórias da força de preensão palmar, polpa-polpa, lateral e tridigital utilizando um dinamômetro de pressão. A sensibilidade dos dedos foi mensurada por meio de monofilamentos de nylon. Foi observado que com o passar do tempo houve melhora da sensibilidade e a força se manteve inalterada.

Responsiveness of the Michigan Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder and Hand questionnaire in carpal tunnel surgery

PURPOSE

Symptom resolution and functional improvement are the 2 primary reasons for patients to seek treatment for carpal tunnel syndrome (CTS). This study aimed to measure the responsiveness of the Michigan Hand Outcomes Questionnaire (MHQ) and Disabilities of the Arm, Shoulder and Hand (DASH) when evaluating outcomes after carpal tunnel surgery.

METHODS

Fifty patients prospectively completed the MHQ and the DASH before and 6 months after open carpal tunnel release. Data were analyzed using paired t tests and responsiveness to clinical change was calculated by using standardized response means (SRMs).

RESULTS

All domains of the MHQ significantly improved after carpal tunnel release: the pain scale had a large SRM of 0.9 and the function scale showed medium responsiveness of 0.6. The combined function/symptom scale of the DASH significantly improved after surgery; the SRM revealed a medium effect of 0.7.

CONCLUSIONS

The MHQ and the DASH are both responsive in measuring outcomes of carpal tunnel surgery. The MHQ has subscales that can measure symptom and function improvement independently. The MHQ and the DASH can be used for outcomes research related to carpal tunnel surgery with the advantage of also being useful for assessing and comparing outcomes for various other hand disorders.

Surgical treatment options for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome is a common disorder, for which several surgical treatment options are available.

OBJECTIVES

To compare the efficacy of the various surgical techniques in relieving symptoms and promoting return to work and/or activities of daily living and to compare the occurrence of side-effects and complications, in patients suffering from carpal tunnel syndrome.

SEARCH STRATEGY

We updated the searches in 2003. We conducted computer-aided searches of the trials register of the Cochrane Neuromuscular Disease Group (searched in July 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (January 1966 to August 2003), EMBASE (January 1980 to August 2003) and tracked references in bibliographies.

SELECTION CRITERIA

Randomised controlled trials comparing various surgical techniques for the treatment of carpal tunnel syndrome.

DATA COLLECTION AND ANALYSIS

Two reviewers performed study selection, assessment of methodological quality and data abstraction independently of each other.

MAIN RESULTS

Twenty-three studies were included in the review. The methodological quality of the trials was fair to good. However, the application of allocation concealment was mentioned explicitly in only one trial. Many studies failed to present the results in sufficient detail to enable statistical pooling. Pooling was also impeded by the vast variety of outcome measures that were applied in the various studies. None of the existing alternatives to standard open carpal tunnel release seem to offer better relief from symptoms in the short- or long-term. There was conflicting evidence about whether endoscopic carpal tunnel release resulted in earlier return to work and/or activities of daily living than open carpal tunnel release.

REVIEWERS' CONCLUSIONS

There is no strong evidence supporting the need for replacement of standard open carpal tunnel release by existing alternative surgical procedures for the treatment of carpal tunnel syndrome.

Median Nerve Excursion during Endoscopic Carpal Tunnel Release

OBJECTIVE

Restriction of the excursion of the nerve has been accepted as a pathogenetic element in carpal tunnel syndrome. The goal of this article was to evaluate the median nerve excursion in the carpal tunnel measured as a function of wrist position before and after endoscopic carpal tunnel release (ECTR) on 28 hands of 22 patients.

METHODS

The position of cylindrical stainless steel markers embedded within the median nerve was measured by a direct radiographic technique. Each upper extremity was examined in three wrist positions. Then, endoscopic release with Menon's technique was performed, and the measurements were repeated.

RESULTS

In this prospective clinical study, most (93%) of the patients experienced resolution of their symptoms. Before and after ECTR, median nerve excursion was linear and was affected by wrist position. Before ECTR, when the wrist was moved from the end of dorsiflexion to the end of palmar flexion, the median nerve underwent a mean total excursion of 28.8 mm at the wrist. A comparison of the before and after ECTR excursion showed no statistical differences in the amount of motion.

CONCLUSION

The single-portal ECTR does not seem to influence the median nerve excursion for the wrist positions studied in patients with carpal tunnel syndrome. The results from this in vivo study showed longitudinal gliding of the median nerve twice as great as in in vitro studies.

A Systematic Review of Reviews Comparing the Effectiveness of Endoscopic and Open Carpal Tunnel Decompression

Controversy persists regarding the benefit of endoscopic carpal tunnel release compared with open carpal tunnel release for pain, numbness, strength, return to work and function, scar tenderness, and complications. For surgeons, a recommended first source of information on treatment effectiveness is a review of high-methodologic-quality articles. This review of reviews was undertaken to answer this clinical question regarding these outcomes. Cochrane, MEDLINE, EMBASE, CINAHL, and HealthSTAR databases were searched using the key words "endoscopic carpal tunnel," with limits "review or overview" and dates from 1989 to present. Five key journals were hand-searched. Any review with a reference to at least one randomized controlled trial that compared endoscopic carpal tunnel release to open carpal tunnel release was to be included. Two reviewers independently scanned titles and abstracts for potential relevance. Selection as relevant was confirmed through a review of full texts. Disagreements were resolved through discussion and consensus. The selected reviews were assessed for methodologic quality on the basis of the scale of Hoving et al. Of 48 articles initially identified, seven pertinent reviews were selected. Of these seven, three reviews of high methodologic quality concurred that there is no difference between the two techniques in symptom relief and that the evidence is conflicting for return to work and function. The risk of permanent median nerve injury does not differ between the techniques. The reviews indicated that the endoscopic carpal tunnel release technique is worse in terms of reversible nerve injury but superior in terms of grip strength and scar tenderness, at least in short-term follow-up. Several trials have not been incorporated in these reviews and statistical pooling has not been conducted. Further systematic review with meta-analysis may permit more definitive conclusions about the relative effectiveness of these two techniques, particularly with regard to return to work and function.

Intracarpal steroid injection is safe and effective for short-term management of carpal tunnel syndrome

A double-blinded placebo-controlled trial was performed to evaluate the use of steroid injections beneath the transverse carpal ligament in the treatment of carpal tunnel syndrome (CTS) refractory to nonsurgical therapy. Forty-three patients received 6 mg betamethasone and lidocaine and 38 patients received 1 ml saline placebo and lidocaine. The primary outcome measure was satisfaction with symptom relief. Thirty patients (70%) in the steroid-treated group were satisfied or highly satisfied compared with 13 (34%) of placebo-treated patients (P < 0.001). Patients receiving steroids also showed significant improvement in median nerve conduction parameters and scores on validated symptom/function questionnaires. Forty-six patients were treated with serial injections for recurrent CTS symptoms. After 18 months, 17 patients reported adequate symptom relief with steroid injection, and 18 patients with unsatisfactory symptom relief were referred for carpal tunnel release surgery. We conclude that although steroid injections are safe and effective for temporary relief of CTS, most patients will eventually require surgery for long-term control of their symptoms.

Median nerve damage during two-portal endoscopic carpal tunnel release

OBJECTIVE

To evaluate the adverse effects of Chow's two-portal endoscopic carpal tunnel release (ECTR) performed by an experienced surgeon on median nerve function in patients with idiopathic carpal tunnel syndrome, as compared to open carpal tunnel release (OCTR).

METHODS

Eighty-seven hands subjected to ECTR and 65 hands subjected to OCTR were reviewed. Both groups of patients were similar with regard to age, gender, and severity of the disease. Both groups were compared for the number of hands showing worsening of motor distal latency, sensory conduction velocity, and sensory disturbance after surgery.

RESULTS

Thirteen hands of 12 patients showed worsening of median nerve function after ECTR, while only one hand showed worsening after OCTR. This difference was statistically significant (p=0.0041).

CONCLUSIONS

Median nerve damage, although transient or not serious, may occur even if the procedure is done correctly.