Long-term outcome after carpal tunnel release and identification of prognostic factors

Does Revision Carpal Tunnel Release Result in Long-Term Outcomes Equivalent to Single Carpal Tunnel Release? A Matched Case-Control Analysis

BACKGROUND

The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR.

METHODS

The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire.

RESULTS

A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery.

CONCLUSION

Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.

Usefulness of the Phalen Test and the Tinel Sign in the Prognosis and the Impact on Quality of Life of Patients with Carpal Tunnel Syndrome Undergoing Classical Open Carpal Tunnel Release

Objective:  To evaluate the usefulness of the Phalen test and the Tinel sign in the prognosis and the impact on quality of life in the clinical course of patients with carpal tunnel syndrome undergoing surgical treatment through the traditional open approach. Methods:  The present is a cohort study on prognosis. We included 115 patients with high probability of receiving a clinical diagnosis of carpal tunnel syndrome with indication for surgical treatment. All patients underwent the Phalen test and Tinel sign and answered the Boston Carpal Tunnel Questionnaire before and after the surgical treatment. Results:  The estimates for the probability of the time until remission of the Phalen test at 2, 4 and 16 weeks postoperatively were of 3.54% (95% confidence interval [95%CI]: 1.16%-8.17%), 0.88% (95%CI: 0.08%-4.38%) and 0.88% (95%CI: 0.08% to 4.38%) respectively, and, for the Tinel sign, they were of 12.39% (95%CI: 7.13%-19.18% ), 4.42% (95%CI : 1.65%-9.36%) and 2.65% (95%CI : 0.70%-6.94%) respectively. There was a reduction in the postoperative score on the Boston Carpal Tunnel Questionnaire of 1.8 points for symptom severity ( p  < 0.001) and of 1.6 points for functional status ( p  < 0.001). Conclusion:  Phalen test remission was earlier than that of the Tinel sign, but, when performed as of the second postoperative week, they were prognostic factors favorable to the clinical course, with improved quality of life.

Long-Term Clinical Results of Carpal Tunnel Release Using Ultrasound Guidance: A Multicenter Pragmatic Study

Purpose

The purpose of this study was to report the 1-year clinical outcomes of carpal tunnel release using ultrasound guidance (CTR-US) performed in a large, real-world population of patients enrolled in a multicenter registry.

Methods

All patients who participated in a postmarket registry study of CTR-US outcomes and provided both preoperative and 1-year postoperative data were included. Main outcomes were the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QDASH), Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS), and Boston Carpal Tunnel Functional Status Scale (BCTQ-FSS) scores at 1 year. Subgroup analysis was performed to assess the effect of patient and procedural factors on 1-year outcomes.

Results

A total of 300 patients (341 hands) were treated by 25 different physicians, including 41 (13.7%) treated with simultaneous bilateral procedures. Mean patient age was 54.2 years, 63% were women, 24% had ≥2 comorbidities, and 54% had symptoms for >2 years. Mean QDASH scores decreased from 40.6 ± 20.6 to 12.2 ± 18.3 at 1 year, BCTQ-SSS scores decreased from 3.0 ± 0.7 to 1.5 ± 0.7 at 1 year, and BCTQ-FSS scores decreased from 2.4 ± 0.8 to 1.4 ± 0.6 at 1 year. Women improved more than men at 1 year for QDASH, BCTQ-SSS, and BCTQ-FSS. Patients treated with simultaneous bilateral procedures had similar 1-year outcomes to those treated with unilateral procedures. Multiple other factors including high body mass index, diabetes status, current tobacco use, rheumatoid/inflammatory arthritis, operation in the dominant hand, higher comorbidity burden, and concurrent ipsilateral procedures did not significantly affect 1-year outcomes. Two patients had revision surgeries in addition to one patient with an infection, and one with a suspected small finger tendon injury.

Conclusions

Patients treated with CTR-US in real-world conditions report significant and clinically meaningful improvements in symptoms and function that are maintained at 1 year. The results are consistent across broad patient demographics and are not affected by performing simultaneous bilateral procedures.

Type of study/level of evidence

Therapeutic IV.

Photobiomodulation Therapy in Carpal Tunnel Release: A Randomized Controlled Trial

Background: Carpal tunnel release (CTR) is widely accepted as an effective treatment for carpal tunnel syndrome. However, the recovery is often delayed and incomplete. Photobiomodulation therapy (PBMT) produces a nonthermal effect on living tissues; it promotes healing, remodels and reduces inflammation of an injured nerve. The purpose of this study was to compare the outcome of CTR between patients who underwent postoperative PBMT and without PBMT. Materials and methods: We recruited 105 patients who had open CTR from January 2019 to January 2021. Fifty-six patients fulfilled the study criteria and were randomized into two groups: with PBMT (n = 28) and without PBMT (n = 28). Demographic and clinical data were obtained preoperatively. The PBMT group had ten 3-min sessions over 3 weeks using 808 nm, 50 mW PBMT to deliver 9 J per session to the CTR incision scar. Clinical outcomes were assessed at 1, 3, and 6 months postoperatively. Data analysis was performed with SPSS software. Results: There were significant improvements in the Functional Status Scale in the Boston Carpal Tunnel Questionnaire (p = 0.018) and pain (visual analogue scales) in the morning (p = 0.019) at 1 month postoperatively in the PBMT group compared with the non-PBMT group. Improvement of tip pinch strength at 3 months (p = 0.022) and 6 months (p = 0.024), lateral pinch strength at 1 month (p = 0.042) and 3 months (p = 0.05), and tripod pinch strength at 3 months (p = 0.005) was significantly better in the PBMT group. Thumb 2-point discrimination (2PD) at 3 months (p = 0.018) and 6 months (p = 0.016) and index finger 2PD at 3 months (p = 0.039) were also significantly improved in the PBMT group. There were no side effects of PBMT reported. Conclusions: Patients who underwent PBMT post-CTR had better outcomes. PBMT may be a valuable adjunct to post-CTR care.

Multiple Compression Syndromes of the Same Upper Extremity: Prevalence, Risk Factors, and Treatment Outcomes of Concomitant Treatment

PURPOSE

Multiple nerve compression syndromes can co-occur. Little is known about this coexistence, especially about risk factors and surgical outcomes. Therefore, this study aimed to describe the prevalence of multiple nerve compression syndromes in the same arm in a surgical cohort and determine risk factors. Additionally, the surgical outcomes of concomitant treatment were studied.

METHODS

The prevalence of surgically treated multiple nerve compression syndromes within one year was assessed using a review of patients' electronic records. Patient characteristics, comorbidities, and baseline scores of the Boston Carpal Tunnel Questionnaire were considered as risk factors. To determine the treatment outcomes of simultaneous treatment, patients who underwent concomitant carpal tunnel release (CTR) and cubital tunnel release (CubTR) were selected. The treatment outcomes were Boston Carpal Tunnel Questionnaire scores at intake and at 3 and 6 months after the surgery, satisfaction 6 months after the surgery, and return to work within the first year.

RESULTS

A total of 7,867 patients underwent at least one nerve decompression between 2011 and 2021. Of these patients, 2.9% underwent multiple decompressions for the same upper extremity within one year. The risk factors for this were severe symptoms, younger age, and smoking. Furthermore, the treatment outcomes of concomitant CTR and CubTR did not differ from those of CubTR alone. The median time to return to work after concomitant treatment was 6 weeks. Patients who underwent CTR or CubTR alone returned to work after 4 weeks.

CONCLUSIONS

Approximately 3% of the patients who underwent surgical treatment for nerve compression syndrome underwent decompression for another nerve within 1 year. Patients who report severe symptoms at intake, are younger, or smoke are at a greater risk. Patients with carpal and cubital tunnel syndrome may benefit from simultaneous decompression. The time to return to work may be less than if they underwent decompressions in separate procedures, whereas their surgical outcomes are comparable with those of CubTR alone.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Is the outcome of a revision carpal tunnel release as good as those of a primary release? A matched cohort study

OBJECTIVE

This study aimed to compare primary and revision carpal tunnel release outcomes in all patients with carpal tunnel syndrome and when corrected for baseline severity and demographics.

METHODS

A total of 903 hands of primary and 132 hands of revision patients underwent carpal tunnel release and patients completed online questionnaires on demographics, clinical severity, and satisfaction. The primary outcome measure, the Boston Carpal Tunnel Questionnaire (BCTQ), was administered at intake and six months after surgery.

RESULTS

The BCTQ total score at six months was better in primary (1.55±0.58) than revision patients (1.94±0.73, p=<0.001), and primary patients improved more on the BCTQ total score (1.10±0.71 vs. 0.90±0.72, p=0.003). In patients matched on similar baseline characteristics using propensity score matching, the BCTQ total score at six months was also better in primary patients (1.65±0.63) than in revision patients (1.92±0.73, p=0.002), and primary patients still had more improvement in BCTQ total score (1.18±0.73 vs. 0.89±0.73, p=0.004).

CONCLUSIONS

This study shows that the outcome after revision carpal tunnel release is only 16% worse compared to primary carpal tunnel release. Preoperative symptom severity, functional status, and demographics may play a role since correcting for these factors reduces the difference in outcome between primary and revision CTR.

Tourniquet Does Not Affect Long-term Outcomes in Minor Hand Surgery: A Randomized Controlled Trial

Surgeons often prefer to use a tourniquet during minor procedures, such as carpal tunnel release (CTR) or trigger finger release (TFR). Besides the possible discomfort for the patient, the effect of tourniquet use on long-term results and complications is unknown. Our primary aim was to compare the patient-reported outcomes 1 year after CTR or TFR under local anesthesia with or without tourniquet. Secondary outcomes included satisfaction, sonographically estimated scar tissue thickness after CTR‚ and postoperative complications.

Surgeon Ratings of the Severity of Idiopathic Median Neuropathy at the Carpal Tunnel Are Not Influenced by Magnitude of Incapability

BACKGROUND

Accurately distinguishing the severity of pathophysiology from the level of symptom intensity and incapability is a foundation of effective treatment strategies under the biopsychosocial paradigm of illness. With respect to idiopathic median neuropathy at the carpal tunnel (the symptoms and signs of which are referred to as carpal tunnel syndrome), surgeons who are more likely to recommend surgery based on the magnitude of symptoms and incapability rather than the severity of neuropathy may be underappreciating and undertreating mental health opportunities and overtreating mild, and on occasion unmeasurable, disease. A survey-based experiment that randomizes elements of the patient presentation can help determine the relative influence of magnitude of incapability on ratings of pathology severity.

QUESTION/PURPOSE

What factors are associated with severity rating of idiopathic median neuropathy at the carpal tunnel on an 11-point ordinal scale?

METHODS

One hundred eight hand and wrist members of the Science of Variation Group (among approximately 200 participants who complete at least one survey-experiment a year related to the upper extremity on average) reviewed seven scenarios of fictional median neuropathy with seven randomized variables: age, gender, limitations of daily activity (incapability), Tinel and Phalen test results, duration of numbness episodes, prevention of numbness with nocturnal splint immobilization, constant numbness, and weakness of palmar abduction. Participants had a mean age of 51 ± 10 years, 90% (97 of 108) were men, and 74% (80 of 108) were subspecialized in hand surgery. Surgeons were asked to rate the severity of idiopathic median neuropathy at the carpal tunnel on a on an 11-point ordinal scale. Factors associated with rated severity were sought in multilevel ordered logistic regression models. Fifteen surgeons did not complete all of their assigned randomized scenarios, resulting in a total of 675 ratings.

RESULTS

After controlling for potentially confounding variables such as magnitude of incapability, factors associated with severity rating on the 11-point ordinal scale included palmar abduction weakness (odds ratio 11 [95% confidence interval 7.7 to 15]), longer duration of symptom episodes (OR 4.5 [95% CI 3.3 to 6.2]), nocturnal numbness in spite of splint immobilization (OR 3.2 [95% CI 2.3 to 4.3]), constant numbness (OR 2.5 [95% CI 1.9 to 3.4]), positive Tinel and positive Phalen test results (OR 2.2 [95% CI 1.6 to 2.9]), and older age (OR 1.6 [95% CI 1.2 to 2.1]).

CONCLUSION

Our results suggest that surgeons rate the severity of idiopathic median neuropathy at the carpal tunnel based on evidence of worse pathophysiology and are not distracted by greater incapability.

CLINICAL RELEVANCE

Surgeons who consider greater incapability as an indication of more severe pathology seem to be practicing outside the norm and may be underappreciating and undertreating the unhelpful thoughts and feelings of worry or despair that consistently account for a notable amount of the variation in symptom intensity and magnitude of incapability.

The association of sensory phenotype and concomitant mood, sleep and functional impairment with the outcome of carpal tunnel surgery

BACKGROUND

Up to 25% of people who have had carpal tunnel release surgery (CTR) fail to report improvement; however, evidence for prognostic indicators in this surgical cohort is limited. To identify candidate prognostic factors, this study investigated the association of quantitative sensory testing (QST) derived sensory phenotype and attendant impairment with patient-reported surgical outcome.

METHODS

With ethical approval and informed consent, this prospective observational longitudinal study recruited patients from two London hospitals. Multimodal phenotyping measures including quantitative sensory testing (QST), pain parameters, insomnia, pain-related worry, mood and function, were evaluated prior to; and at 3- and 6-months post-surgery. Pain in median nerve distribution with electrophysiologically confirmed conduction delay and DN4 score ≥ 4 was defined as neuropathic. Primary outcome was patient-rated change at 6 months, dichotomised as poor outcome; "worse" or "no change" and good outcome; "slightly better", "much better" or "completely cured".

RESULTS

Seventy-six patients participated. Prior to surgery, substantial heterogeneity in established categories of somatosensory function was observed with 21% of participants categorised as having a healthy sensory phenotype; 29% with thermal hyperalgesia; 32% mechanical hyperalgesia and 18% sensory loss. Seventy six percent of participants were classified as having neuropathic pain, 33% with high levels of pain related worry and 64% with clinical insomnia. Observed differences in pain, sleep impairment, psychological factors and function, between sensory phenotypic groups, was not significant. At 3- and 6-months post-surgery there was significant improvement in all phenotyping measures with a moderate to large effect size. Thermal and mechanical measures of somatosensation improved (p < 0.001), as did functional ability (p < 0.001). Symptom severity diminished (p < 0.001), as did pain-related worry (p < 0.001), anxiety (p = 0.02) and insomnia (p < 0.001). Patient-rated surgical outcome was good in 92% of the cohort, poor in 8%. Baseline sensory phenotype category was not associated with surgical outcome however pain-related worry, anxiety and functional interference were significantly associated with outcome (p ≤ 0.05).

CONCLUSION

In patients undergoing carpal tunnel surgery, pain-related worry, anxiety and pain functional interference are candidate prognostic outcome factors and require further elucidation.

Relationship between clinical outcomes and nerve conduction studies before and after surgery in patients with carpal tunnel syndrome

Background

Nerve conduction study (NCS) is the only useful test for objective assessment of carpal tunnel syndrome (CTS). However, the relationship between pre- and postoperative NCS and clinical outcomes was unclear. This study aimed to determine whether pre- and postoperative (6 months) NCS could predict patient-oriented and motor outcomes (6 and 12 months postoperatively) in patients with CTS.

Method

Of the 85 patients with CTS, 107 hands were analyzed from March 2011 to March 2020. All patients underwent open carpal tunnel release and were examined using the disabilities of the arm, shoulder and hand (DASH) questionnaire and grip strength (GS) preoperatively and 6 and 12 months postoperatively. Moreover, NCS was examined preoperatively and 6 months postoperatively. Distal motor latency (DML) and sensory conduction velocity (SCV) were the parameters used for NCS. The correlation coefficient between NCS and DASH or GS was calculated. A receiver operating characteristic curve was utilized to determine the NCS threshold value to predict DASH and GS improvement.

Results

The average scores of GS preoperatively and 6 and 12 months postoperatively were 21.3, 22.3, and 22.8, respectively. On the other hand, the average scores of DASH preoperatively and 6 and 12 months postoperatively were 28.8, 18.3, and 12.2, respectively. The average NCS scores (DML and SCV) preoperatively/6 months postoperatively were 7.3/5.4 and 27.8/36.7, respectively. Preoperative NCS did not correlate with DASH and GS. Postoperative SCV correlated with the change in grip strength (6–12 months, r = 0.67; 0–12 months, r = 0.60) and DASH (0–12 months, r = 0.77). Moreover, postoperative DML correlated with the change in DASH (6–12 months, r = − 0.33; 0–12 months, r = − 0.59). The prediction for the improvement of GS/DASH achieved a sensitivity of 50.0%/66.7% and a specificity of 100%/100%, at an SCV cutoff score of 38.5/45.0 or above. The prediction for improvement of GS/DASH achieved a sensitivity of 83.3%/66.7% and a specificity of 100%/66.7% at a DML cutoff score of 4.4/4.4 or below.

Conclusion

NCS at 6 months postoperatively can be used to predict the improvement of clinical outcome after 6 months postoperatively in patients with CTS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04771-y.

The Accuracy of a Screening System for Carpal Tunnel Syndrome Using Hand Drawing

When carpal tunnel syndrome (CTS), an entrapment neuropathy, becomes severe, thumb motion is reduced, which affects manual dexterity, such as causing difficulties in writing; therefore, early detection of CTS by screening is desirable. To develop a screening method for CTS, we developed a tablet app to measure the stylus trajectory and pressure of the stylus tip when drawing a spiral on a tablet screen using a stylus and, subsequently, used these data as training data to predict the classification of participants as non-CTS or CTS patients using a support vector machine. We recruited 33 patients with CTS and 31 healthy volunteers for this study. From our results, non-CTS and CTS were classified by our screening method with 82% sensitivity and 71% specificity. Our CTS screening method can facilitate the screening for potential patients with CTS and provide a quantitative assessment of CTS.

Analysis of the Long-Term Outcome in Open Carpal Tunnel Release Surgeries with and without External Neurolysis of Median Nerve, Using Boston Carpal Tunnel Questionnaire (BCTQ)-Hindi Version

Background  The effectiveness of open carpal tunnel release (OCTR) in treating carpal tunnel syndrome (CTS) is well known. However, the role of ancillary external neurolysis of the median nerve is not well-documented. The Boston carpal tunnel questionnaire (BCTQ) is a commonly used disease-specific outcome instrument for CTS, which is validated across major languages of the world. No such validated Hindi version of BCTQ exists.

Objectives  To analyze and compare the long-term outcome in patients who underwent OCTR alone and OCTR with external neurolysis of the median nerve, using BCTQ–Hindi version, while checking its validity.

Materials and Methods  A retrospective, cross-sectional study was conducted at a tertiary care institute. The BCTQ was translated into Hindi language by a language expert. Eighty-four consecutive patients who underwent either unilateral/bilateral OCTR, with or without external neurolysis of the median nerve, between 2009 and 2019 were included in the study. Outcome analysis was done using BCTQ–Hindi version and patient satisfaction scoring. BCTQ–Hindi version was examined for statistical validity. Subgroup analysis of the outcome based on surgical technique (OCTR vs. OCTR with external neurolysis) used was carried out.

Results  Response rate was 80.9%. Total hands evaluated were 108. BCTQ–Hindi version showed statistical validity. Overall symptom severity score (SSS) and functional severity score (FSS) were 1.14 ± 0.4 and 1.12 ± 0.35, respectively. Subgroup analysis of outcome revealed statistically significant results in favor of OCTR with external neurolysis of the median nerve.

Conclusions  BCTQ–Hindi version is statistically validated. OCTR with external neurolysis of the median nerve is a promising avenue in surgical management of CTS. Further prospective studies are warranted.

Validation of the Dutch Version of the Boston Carpal Tunnel Questionnaire

The Boston Carpal Tunnel Questionnaire (BCTQ) is a scale that has been developed specifically for carpal tunnel syndrome (CTS). It consists of the Functional Status Scale (FSS) and the Symptom Severity Scale (SSS). It is the most widely used patient reported outcome measure in CTS and has been validated in many languages. Although already widely used, psychometric properties of the Dutch version of the BCTQ are yet unknown. The aim of this study was to assess the validity, reliability, responsiveness, and acceptability of the Dutch version. Moreover, this paper focuses the longitudinal validity (the use after an intervention) of the BCTQ, which has not been investigated before. A total of 180 patients completed the BCTQ in addition to a six-point Likert scale for perceived improvement, before and about 6–8 months after carpal tunnel release (CTR). Principal factor analysis revealed that the FSS is unidimensional, consisting of a single latent factor (“functionality”) and has a high internal consistency (Cronbach's α = 0.825). However, the SSS has three dimensions, which are all highly internally consistent: “daytime symptoms” (Cronbach's α = 0.805), “nighttime symptoms” (Cronbach's α = 0.835), and “operational capacity” (Cronbach's α = 0.723). Post-treatment, the FSS still consisted of one factor, but the SSS changed in dimensionality, as it had only two factors left post-treatment. The ΔFSS and ΔSSS had good correlation with the six-point Likert scale for perceived improvement (r = 0.524; p < 0.01 and r = 0.574; p < 0.01, respectively), a moderate correlation between FSS and pinch grip (r = 0.259; p < 0.01) was found, and a weak correlation between SSS and pinch grip (r = 0.231; p < 0.01) was found. Standard Response Mean for FSS and SSS was 0.76 and 1.49, respectively. Effect size was 0.92 and 1.96, respectively, both indicating a good responsiveness. Response rate was high (82–84%). We concluded that the Dutch version of the BCTQ has a proper reliability, validity, responsiveness, and acceptability to assess the symptom severity and functional disabilities of CTS patients. Because of multidimensionality, we would recommend to create sum scores of the four different dimensions instead of two. Caution is required when interpreting the results postoperatively, due to the insufficient longitudinal validity of the SSS.