A Systematic Review of Randomised Control Trials Evaluating the Efficacy and Safety of Open and Endoscopic Carpal Tunnel Release

Endoscopic Versus Open Carpal Tunnel Release: An Umbrella Review and a Meta-analysis

INTRODUCTION

Whether endoscopic carpal tunnel release (ECTR) versus open carpal tunnel release (OCTR) has superior outcomes remains a controversial topic. Therefore, we sought to perform an umbrella review and meta-analysis to compare ECTR and OCTR with regards to (1) postoperative functional ability, (2) operative outcomes, and (3) time to return to work.

METHODS

A PubMed, Scopus, and Cochrane database search was conducted for all meta-analyses comparing ECTR and OCTR performed between 2000 and 2022 in accordance to PRISMA and Joanna Briggs Institute guidance for umbrella reviews. The primary outcomes were as follows: (1) functional ability-symptoms severity, postoperative grip strength, postoperative pinch strength, 2-point discrimination, and pain; (2) operative outcomes-operation time, total complications, nerve injury, and scar-related complication; and (3) time to return to work. Quality was assessed using the Assessment of Multiple Systematic Reviews. Pooled analysis was performed to compare several clinical outcome measures between groups, depending on the availability of data using Review Manager Version 5.2.11.

RESULTS

A total of 9 meta-analyses were included, 5 were of high quality and 4 were moderate quality. For functional ability, ECTR was associated with better pinch strength after 3 months (0.70, 95% confidence interval [CI] = 0.00, 1.40, P = 0.05) and 6 months (0.77, 95% CI = 0.14, 1.40, P = 0.02, I2 = 84%). For return to work, OCTR was associated with longer return to work compared with ECTR (-10.89, 95% CI = -15.14, -6.64, P < 0.00001, I2= 83%). There were no significant differences between OCTR and ECTR in the hand function, symptom severity, grip strength, pain, operation time, and total complications.

CONCLUSIONS

In an umbrella review and meta-analysis of ECTR versus OCTR, ECTR was associated with a higher pinch strength, and a shorter time to return to work. Differences in major complications, such as nerve injury, were unclear due to statistical inconsistency and bias.

State of the art review. Complications after carpal tunnel release

Carpal tunnel release (CTR) is the most performed surgery of the upper extremity. It is effective but not without complications. This state-of-the-art review covers most common intra- and postoperative complications after CTR. As endoscopic carpal tunnel release (ECTR) has developed over time, severe complications, such as nerve lesions, have diminished. ECTR still has a higher risk on transient nerve lesions. Open CTR on the other hand has a higher incidence of wound-related problems, including scar tenderness, irrespective of incision used. Most complications, such as pillar pain and infection, are ill-defined in the literature, leaving the exact incidence unknown and proposing challenges in treatment. The same is true for failure of treatment. Optimizing the length and location of incisions has played a vital role in reducing intra- and postoperative complications in CTR. It is expected that technical advances, such as ultrasound-guided percutaneous carpal tunnel release, will continue to play a role in the future.Level of evidence: V.

Endoscopic carpal surgery in carpal tunnel syndrome: A systematic review

Objective

Endoscopic carpal tunnel release has become increasingly popular and has shown the advantage of early recovery of hand function with minimal morbidity. In this systematic review, we aimed to summarize the currently available data and describe the reported advantages and disadvantages of endoscopic carpal tunnel surgery for treating carpal tunnel syndrome.

Methods

In this study, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, which is a set of reporting requirements for systematic reviews and meta-analyses. The search strategy with MeSH terms was "MeSH (carpal tunnel syndrome) AND (endoscopic)" Filters: in the last 5 years, English-on February 27th, 2022. A total of 131 articles fulfilled the first screening criteria. A detailed analysis of those articles identified 39 that matched the criteria, of which 14 were considered appropriate for this analysis after applying the complete inclusion and exclusion criteria.

Results

A total of 14 studies met the eligibility criteria. Analysis of those studies found that all types of portals in endoscopic carpal tunnel release reduced postoperative pain at a short-term follow-up. There was no evidence to suggest the superiority of the single- or two-portal techniques in terms of outcomes. In terms of pain relief, symptom resolution, patient satisfaction, duration to return to work, and adverse events, this early use of endoscopic carpal tunnel release produced satisfactory outcomes. Further studies comparing the number of portals are needed.

Conclusion

Endoscopic carpal tunnel surgery for treating carpal tunnel syndrome is effective and both single- and dual-portal techniques provide advantages in terms of early recovery and minimal morbidity.

Update on surgical procedures for carpal tunnel syndrome: What is the current evidence and practice? What are the future research directions?

Carpal tunnel syndrome (CTS) is a multifactorial compression neuropathy. It is reported to be very common and rising globally. CTS’s treatment varies from conservative measures to surgical treatments. Surgery has shown to be an effective method for more severe cases. However few unclear aspects and room for further research and improvements still remains. We performed a narrative literature review on the most up to date progress and innovation in terms of surgical treatments for CTS. The simple algorithm of leaving the choice of the surgical method to surgeons’ preference and experience (together with consideration of patients’ related factors) seem to be the best available option, which is supported by the most recent metanalysis and systematic reviews. We suggest that surgeons (unless in presence of precise indications towards endoscopic release) should tend to perform a minimally invasive open approach release, favoring the advantage of a better neurovascular structures visualization (and a consequent higher chance to perform a complete release with long term relief of symptoms) instead of favoring an early reduction (in the first postoperative days) of immobilization and pain. Research towards a universally accepted standardization should be aimed for by the researchers, who have failed to date to sufficiently limit bias and limitations.