Long-term outcomes of carpal tunnel release: a critical review of the literature

Clinical-applied anatomy of the carpal tunnel regarding mini-invasive carpal tunnel release

BACKGROUND

Carpal tunnel release is a widely performed procedure. Despite a high success rate, iatrogenic neurovascular injuries can occur which lead to a painful and unsatisfying outcome. This study conducted a detailed examination of the anatomy of the carpal tunnel and the proximity of neurovascular structures that are particularly susceptible to injury, especially in the context of minimally invasive carpal tunnel release procedures.

PATIENTS AND METHODS

The anatomy of the carpal tunnel of 104 wrists of 52 body donors was examined. The precise anatomical location and the presence of variations were recorded for the median nerve, ulnar nerve, ulnar artery and Berrettini branch. The distance between the median nerve, the ulnar artery, the ulnar nerve, and the Berrettini branch was measured in a proximo-distal and radio-ulnar direction in relation to the distal ulnar end of the carpal tunnel.

RESULTS

The authors identified four main dangerous anatomical situations. (1) A proximal separation of the Long-Finger/Ring-Finger branch of the median nerve together with a narrow safe-zone; (2) an ulnar take-off of the recurrent muscle branch of the median nerve with a close radio-ulnar distance to the distal ulnar end of carpal tunnel; (3) an ulnar arterial arch lying close to the transverse carpal ligament; and (4) a proximal Berrettini branch also lying close to the latter. All situations are illustrated by photographs. Additionally, the authors present a sonographic carpal tunnel assessment protocol in order to reduce the risk of injury of any neurovascular structure in the proximity of the carpal tunnel.

CONCLUSION

Certain patients may inherently face an increased risk of neurovascular injuries during minimally invasive carpal tunnel releases due to their anatomical variations. Four potentially risky scenarios were clearly illustrated. Consequently, one may consider conducting a preoperative ultrasound assessment of neurovascular structures at risk, when endoscopic or ultrasound-guided tunnel release are planned. In high-risk patients, open surgery should be preferred.

LEVEL OF EVIDENCE

II.

The Effect of Patient-Reported Allergies on Patient-Reported Outcomes in Carpal Tunnel Release

BACKGROUND

Patient-reported allergies have been shown to be a risk factor for poor surgical outcomes in a variety of orthopedic procedures. The relationship between patient-reported allergies and outcomes in carpal tunnel surgery remains unclear.

METHODS

A retrospective electronic medical chart review was conducted on 390 patients who underwent primary carpal tunnel releases, without concomitant procedures, who completed preoperative and postoperative Quick Disabilities of Arm, Shoulder, and Hand or Patient-Rated Wrist Evaluation scores, with a minimum of 1-year follow-up. Patient demographic data and patient-reported outcome measures were collected. Patients were grouped based on the number of allergies reported (≤3 allergies or ≥4 allergies), and statistical analysis was performed.

RESULTS

Three hundred and ninety patients were included in the analysis (347 patients [89.0%] with ≤3 allergies; 43 patients [11.0%] with ≥4 allergies). Patients were predominantly female (n = 243, 62.3%), and the median age at surgery was 61 years. Patients with ≥4 allergies were more likely to be female (88.4% vs 59.1%), older (64.3 years vs 60.3 years), and more likely to be taking psychotropic medication (51.2% vs 28.2%). No differences were seen in patient-reported outcomes at any time point preoperatively or postoperatively, with both groups showing similar postoperative improvement.

CONCLUSIONS

Patients with a high number of reported allergies have similar improvement in patient-reported outcomes following carpal tunnel release as low-allergy cohorts.

Long-Term Functional Outcomes and Quality of Life Following Carpal Tunnel Release Surgery

This study investigates the long-term efficacy of carpal tunnel release surgery (CTR) on patient outcomes. We aimed to assess symptom severity, functional limitations, and quality of life in a large cohort (n = 186) at least five years post-surgery via a retrospective cross-sectional design that evaluated participants using the validated Boston Carpal Tunnel Questionnaire (BCTQ) over a phone interview. The BCTQ measures symptom severity, functional limitations, and quality of life specific to carpal tunnel syndrome. Seventy-three percent (73.1%) of patients reported complete resolution of symptoms and functional limitations (BCTQ = 1) with an average follow-up of 11 years. No statistically significant decline in BCTQ scores was observed over time. Univariate analysis revealed a significant association between poorer outcomes and older age at surgery and current unemployment. Carpal tunnel release surgery demonstrates long-term effectiveness in relieving symptoms and improving function in most patients. These findings contribute to the understanding of CTR's impact on patient well-being beyond short-term outcomes.

Revision Endoscopic Carpal Tunnel Release: An Update on Technique and Outcomes

Background

Carpal tunnel release is among the most frequently conducted upper extremity procedures. While it typically provides patients with improved sensation, decreased pain, and improved function, a small percentage of cases require revision due to failed initial surgery. Consequently, adoption of endoscopic techniques for carpal tunnel revision procedures is beginning to be explored.

Methods

A retrospective analysis was conducted of postoperative clinical visits and patient-reported outcome measures for four patients who had undergone five endoscopic revision carpal tunnel release procedures (one patient had bilateral disease). All five cases had symptoms consistent with recurrent carpal tunnel syndrome.

Results

One hundred percent (5 of 5) of cases resulted in patients reporting symptom improvement. Postoperative clinical visits and improved patient-reported outcome measures (QuickDash, PROMIS Upper Extremity, VAS Pain, PSEQ, PHQ, and Surgery Satisfaction) scores from baseline to 6 weeks demonstrated successful postoperative function and symptom resolution. Five of five cases resulted in patients resuming normal activities without restrictions within 1-5 weeks, with an average of 3.4 weeks.

Conclusions

Preliminary findings suggest the endoscopic revision procedure may be safe and effective for patients with recurrent carpal tunnel syndrome, extending the indications to include scars proximal to the wrist crease. Moreover, this minimally invasive procedure facilitates a transition back to normal activities and avoids incisions on weight-bearing surfaces of the palm. Adopting endoscopic revision may reduce the need for prolonged postoperative care and physical therapy. However, due to the limited sample size of five patients, further investigation with larger cohorts is warranted to confirm these observations.

Risk of carpal tunnel syndrome among patients with osteoarthritis: a US population-based study

BACKGROUND

Carpal tunnel syndrome (CTS), an entrapment neuropathy caused by pressure of the median nerve, is a progressive condition that can lead to a decreased quality of life. Studies suggest an association between CTS and arthritis; however, previous studies examining osteoarthritis (OA) and CTS are limited in number, scope and study design. This study estimated the incidence and risk of CTS among patients with OA, both overall and by specific joints, in a large population-based cohort in the United States.

METHODS

Patients from the Optum claims database aged ≥ 45 years and diagnosed with OA between January 1, 2018, and December 31, 2022, were eligible for the OA cohort. The non-OA cohort included those without a diagnosis of OA at the index date and no history of OA for 12 months pre-index. Baseline characteristics were balanced using propensity score matching. The risk of CTS in the OA and non-OA cohort were evaluated using incidence rates and adjusted hazard ratios that were estimated using Cox regression.

RESULTS

After applying the inclusion/exclusion criteria, 3,610,240 of the 6,023,384 adults with a diagnosis of OA remained in the OA cohort. After propensity-score matching, each cohort included 1,033,439 individuals. The incidence rates for CTS per 1000 person-years were 7.35 (95% confidence interval [CI] 7.21-7.49) in the OA cohort and 1.44 (95% CI 1.38-1.50) in the non-OA cohort. The risk of developing CTS in patients with OA was ~ 4 times that of patients without (hazard ratio = 3.80; 95% CI 3.54-4.07). This increased risk was found across all OA joint types, with OA of the hand/wrist having the highest risk for CTS. Additionally, multiple OA joints presented a higher risk compared with a single affected joint.

CONCLUSIONS

OA increases the risk of CTS, but this is not limited to patients with hand/wrist OA, suggesting a systemic impact of OA on CTS. While the risk appears highest for patients with hand/wrist OA, patients with more distant affected joints like knee or hip also have an increased risk of CTS.

Revision Carpal Tunnel Release Following Endoscopic Compared With Open Decompression

Importance

Carpal tunnel release (CTR) technique may influence the likelihood of revision surgery. Prior studies of revision CTR following endoscopic CTR (ECTR) compared with open CTR (OCTR) have been limited by sample size and duration of follow-up.

Objective

To estimate the incidence of revision CTR following ECTR compared with OCTR in a national cohort.

Design, Setting, and Participants

This retrospective cohort study used data from the US Veterans Health Administration. Participants included all adults (age ≥18 years) undergoing at least 1 outpatient CTR from October 1, 1999, to May 20, 2021. Data were analyzed from May 21, 2021, to November 27, 2023.

Exposure

Index CTR technique.

Main Outcomes and Measures

The primary outcome was time to revision CTR, defined as repeat ipsilateral CTR during the study period. Secondary outcomes were indications for revision, findings during revision, and additional procedures performed during revision.

Results

Among 134 851 wrists from 103 455 patients (92 510 [89.4%] male; median [IQR] age, 62 [53-70] years) undergoing at least 1 CTR, 1809 wrists underwent at least 1 revision at a median (IQR) of 2.5 (1.0-3.8) years. In competing-risks analysis, the cumulative incidence of revision was 1.06% (95% CI, 0.99%-1.12%) at 5 years and 1.59% (95% CI, 1.51%-1.67%) at 10 years. ECTR was associated with increased hazard of revision CTR compared with OCTR (adjusted hazard ratio [aHR], 1.56; 95% CI, 1.34-1.81; P < .001). The risk difference for revision CTR associated with ECTR compared with OCTR was 0.57% (95% CI, 0.31%-0.84%) at 5 years (number needed to harm, 176) and 0.72% (95% CI, 0.36%-1.07%) at 10 years (number needed to harm, 139). Regardless of index CTR technique, the most common indication for revision was symptom recurrence (1062 wrists [58.7%]). A reconstituted transverse carpal ligament (TCL) was more common after ECTR compared with OCTR, whereas scarring of the overlying tissues and of the median nerve itself were more common following OCTR. Incomplete transverse-carpal-ligament release was observed in 251 of the wrists undergoing revision CTR (13.94%) and was more common among revisions following ECTR (odds ratio, 1.62; 95% CI, 1.11-2.37; P = .01).

Conclusions and Relevance

In this cohort study of revision CTR in the Veterans Health Administration, ECTR was associated with increased risk of revision compared with OCTR, but the absolute risk was low regardless of technique. Intraoperative findings at revision varied significantly according to index CTR technique.

Long-Term Outcomes of Ultrasound-Guided Thread Carpal Tunnel Release and Its Clinical Effectiveness in Severe Carpal Tunnel Syndrome: A Retrospective Cohort Study

Ultrasound-guided thread carpal tunnel release (TCTR) was proposed as an effective and safe surgical technique with faster recovery and fewer complications. This study was conducted to confirm the long-term outcomes after TCTR and verify its clinical effectiveness in severe carpal tunnel syndrome (CTS) for more insights into TCTR procedure. A total of 168 TCTR procedures were performed in 152 individual patients by two physiatrists during 36-month period. In an assessment of 82 hands, surgical outcomes of 2 years after TCTR could be obtained, and the grade 6 CTS group of 21 hands, classified as extremely severe grade by Bland's classification, was compared with other severity groups (grade 1-5). The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) was used to assess surgical outcomes. No adverse events occurred in all cases including the case of severe CTS and anatomical variants. TCTR showed significant improvement in BCTQ scale within 1-2 weeks, which continued up to 2 years with no recurrence (p < 0.01). Although slower and more progressive than the other severity group, there was also significant improvement relative to the BCTQ scale around 4 weeks after procedure in the grade 6 CTS group (p < 0.05). With the familiarity of ultrasound, ultrasound-guided TCTR is an effective and reliable surgical treatment for CTS in long-term outcomes and in severe CTS.

Carpal tunnel syndrome

Median neuropathy at the wrist, commonly referred to as carpal tunnel syndrome (CTS), is the most common entrapment neuropathy. It is caused by chronic compression of the median nerve at the wrist within the space-limited carpal tunnel. Risk factors that contribute to the etiology of compression include female gender, obesity, work-related factors, and underlying medical conditions, such as hypothyroidism, pregnancy, and amyloidosis. The diagnosis is made on clinical grounds, although these can be confounded by anatomical variations. Electrodiagnostic studies, which are specific and sensitive in diagnosing CTS, support the diagnosis; however, a subgroup may present with normal results. The advent of imaging techniques, including ultrasound and MRI, further assists the diagnostic process. The management of CTS is divided into the nonsurgical approaches that include hand therapy, splinting and corticosteroid injection, and surgical decompression of the carpal tunnel. Although several surgical techniques have been developed, no one method is more effective than the other. Each of these management approaches are effective at providing symptom relief and are utilized at different severities of the condition. There is, however, a lack of consensus on standardized diagnostic criteria, as well as when and to whom to refer patients for surgery.

Understanding the Learning Curve of Carpal Tunnel Release With Ultrasound Guidance: A Review

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy and can be treated through carpal tunnel release (CTR) if nonoperative treatments fail. CTR can be performed through a variety of techniques, including traditional open, mini-open, endoscopic, and CTR with ultrasound guidance (CTR-US). The evidence on endoscopic CTR is mixed, due to a higher potential for nerve injury with endoscopic CTR compared to traditional open CTR. CTR-US offers the potential advantage of allowing the visualization of all key anatomical structures, combined with a very small incision and minimal soft tissue insult. As with any ultrasonographic technique or procedure, the learning curve needs to be considered for any provider considering adopting CTR-US. However, literature on ultrasound use around the wrist, including early evidence on the learning curve of CTR-US specifically, demonstrates this skill can be learned relatively quickly by providers with a wide range of prior experience in ultrasound and CTR. Overall, there is a need for high-quality studies comparing different CTR techniques, particularly CTR-US, as it offers the potential for considerable cost savings.

Effectiveness of high intensity laser therapy on pain, grip strength and median nerve conductivity in pregnant women with carpal tunnel syndrome: A randomized controlled trial

STUDY DESIGN

Single-blind randomized controlled trial.

INTRODUCTION

High-intensity laser therapy (HILT) was recently introduced to the physiotherapy field as a treatment option for patients with carpal tunnel syndrome (CTS). However, evidence about its effectiveness on pregnant women with CTS is sparse.

PURPOSE OF STUDY

To test the effectiveness of HILT combined with a conventional physical therapy program to reduce pain intensity, sensory and motor nerve distal latency, and increase grip strength in pregnant women with CTS compared with the physical therapy alone.

METHODS

Fifty-four pregnant women with mild to moderate CTS were randomized and further allocated into two groups. The HILT group (n = 27) received both HILT and conventional physical therapy, and the control group (n = 27) received only physical therapy, including nerve and tendon gliding exercises and the use of an orthotic device. Participants received the interventions at the University Hospital (omitted for review) three times per week for 5 weeks. An 11-points numerical pain rating scale, electromyography, and a handheld dynamometer were used for data collection before and after the treatment.

RESULTS

Participants from both groups presented significant improvement in the median nerve motor nerve distal latency (MNDL), sensory nerve distal latency, numerical pain rating scale, and handgrip strength after the intervention. The between-group difference showed more improvements in participants of the HILT group on reducing pain intensity, mean difference (MD) = -3.11 (-4.1 to 2.1), and sensory nerve distal latency, MD = -0.3 (-0.5 to -0.1) compared with the control group.

DISCUSSION

HILT produced greater improvement in outcomes of pregnant women with mild to moderate CTS whichsuggests that adding HILT to traditional CTS physical therapy protocol is beneficial and safe.

CONCLUSIONS

High-intensity laser therapy combined with a standard physical therapy program for CTS in pregnant women is better than the physical therapy program alone to improve pain intensity and median nerve sensory distal latency.

Carpal Tunnel Decompression Under Wide Awake Local Anaesthesia No Tourniquet Technique (WALANT): A Cost Effective and Outcome Analysis

Introduction Wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, resource-friendly, and safe. This can be used as an alternative to hand surgery procedures in outpatient units. It can be performed in clinics or operating rooms. Methods We retrospectively evaluated the outcomes of WALANT for carpal tunnel decompression (CTD) over two years. Measured results include wound infections, relief of symptoms, paraesthesia, haematoma, Visual Analogue Scale (VAS), hospital anxiety and depression scale score (HADS) and cost-effectiveness. Results Eighteen patients underwent CTD under the WALANT technique over two years. VAS score was recorded at 3.1 ± 1.2 during the procedure and 1.67 ± 0.933 at two weeks follow-up. Persistent paraesthesia was found in only one patient at follow-up. Minimal bleeding was recorded during the procedure. No wound infections, revision surgery or post-operative haematoma formation were found. Hospital Anxiety and Depression Scale (HADS) was reported as 4.77 ± 2.1 after surgery. WALANT was also cost-effective, with an overall amount of £20. Conclusion Performing carpal tunnel decompression under WALANT in one stop upper limb clinic is a safe and cost-effective technique with no significant patient-related complications.

Carpal Tunnel Syndrome: Neuropathic Pain Associated or Not with a Nociplastic Condition

Carpal tunnel syndrome (CTS) has been traditionally classified as primarily a neuropathic condition with or without pain. Precision medicine refers to an evidence-based method of grouping patients based on their susceptibility to biology, prognosis of a particular disease, or in their response to a specific treatment, and tailoring specific treatments accordingly. In 2021, the International Association for the Study of Pain (IASP) proposed a grading system for classifying patients into nociceptive, neuropathic, or nociplastic phenotypes. This position paper presents data supporting the possibility of subgrouping individuals with specific CTS related-pain into nociceptive, neuropathic, nociplastic or mixed-type phenotypes. Carpal tunnel syndrome is a neuropathic condition but can also be comorbid with a nociplastic pain condition. The presence of extra-median symptoms and the development of facilitated pain processing seem to be signs suggesting that specific CTS cases can be classified as the nociplastic pain phenotype. The clinical responses of therapeutic approaches for the management of CTS are inconclusive. Accordingly, the ability to identify the predominant pain phenotype in patients with CTS could likely be problematic for producing efficient treatment outcomes. In fact, the presence of a nociplastic or mixed-type pain phenotype would explain the lack of clinical effect of treatment interventions targeting the carpal tunnel area selectively. We propose a clinical decision tree by using the 2021 IASP classification criteria for identifying the predominant pain phenotype in people with CTS-related pain, albeit CTS being a priori a neuropathic pain condition. The identification of a nociplastic-associated condition requires a more nuanced multimodal treatment approach to achieve better treatment outcomes.

Evaluating the underreporting of patient-reported outcomes in carpal tunnel syndrome randomized controlled trials

CONTEXT

In recent years, patient-centered healthcare has become a primary concern for researchers and healthcare professionals. When included in randomized controlled trials (RCTs), patient-reported outcome (PRO) measures serve a critical role in supplementing efficacy outcomes with a patient perspective.

OBJECTIVES

The goals of this study are to evaluate the reporting completeness of PROs within literature concerning carpal tunnel syndrome (CTS) utilizing the Consolidated Standards of Reporting Trials Patient-Reported Outcomes (CONSORT-PRO) extension.

METHODS

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) for published RCTs relating to CTS with at least one PRO measure from 2006 to 2020. Two investigators screened all RCTs for inclusion utilizing Rayyan (https://rayyan.qcri.org/), a systematic review screening platform. In an independent, masked fashion, investigators then evaluated all RCTs utilizing the CONSORT-PRO adaptation and Cochrane Collaboration Risk of Bias (RoB) 2.0 tool. Bivariate regression analyses were utilized to assess relationships between trial characteristics and completeness of reporting.

RESULTS

Our search returned 374 publications, yet only 31 unique RCTs met the inclusion criteria. The mean overall percent of adherence for CONSORT-PRO was 41%. Our secondary outcome-assessing study characteristics-indicated significantly higher completeness of reporting in the absence of a conflict of interest statement (p<0.05), 'some concerns' for bias (p<0.005), and when journals required the use of the CONSORT statement (p<0.005). The RoB assessment determined overall suspicion for bias among included RCTs, with 35% (n=11/31) being labeled as 'high,' 58% (n=18/31) as 'some concerns,' and 7% (n=2/31) as 'low.'

CONCLUSIONS

Our study indicated that the completeness of CONSORT-PRO reporting was deficient within CTS trials. Because of the importance placed on PROs in clinical practice, we recommend adherence to CONSORT-PRO prior to publication of RCTs to increase the understanding of various interventions on patients' quality of life (QoL).

A five-year retrospective cohort study of carpal tunnel surgery complications in an Australian population

BACKGROUND

Carpal tunnel syndrome is a common compressive neuropathy. There is a lack of comprehensive studies evaluating carpal tunnel release (CTR) complications in Australia. This study aimed to evaluate complication rates associated with open and endoscopic CTR in an Australian population, and to identify associated risk factors.

METHODS

Retrospective cohort study of 1287 CTR from 2015 to 2020. Methods of release were endoscopic, open and surgery concomitant with synovectomy or other. Outcomes included wound infection, dehiscence, nerve injury, complex regional pain syndrome, incomplete release, and re-operation. Statistical analysis included Chi-squared test, Fisher's exact test, Odds ratio and logistic regression.

RESULTS

There were 71 total complications (5.5%), including 35 Clavien-Dindo IIIb complications. There was no difference in complication rates for endoscopic (3.3%) versus open (8.3%) CTR (P = 0.18). The overall rate of complications was higher in CTR with concomitant surgery (8.5%) compared to CTR alone (5.2%), though this was not statistically significant (P = 0.058). There was no association between rates of complications and immune suppression (p = 0.55), rheumatoid disease (P = 0.61), or smoking status (P = 0.72). Diabetes mellitus was associated with an increased risk of Clavien-Dindo IIIb complications (P = 0.028, OR 2.15, 95% CI 1.07-4.32). There was no association between surgical experience and complication rate (P = 0.55).

CONCLUSION

Open and endoscopic CTR surgeries have similar rates of complications. Diabetes is associated with higher rates of Clavien-Dindo IIIb complications. Identification of high-risk patients allows for the application of risk-mitigation strategies in the perioperative setting.

Effectiveness of an Endoscopic Recurrent Branch Release Procedure Combined with Standard Endoscopic Carpal Tunnel Release Surgery Compared to Standard Endoscopic Carpal Tunnel Release Surgery Alone: A Propensity Score-Matched Study

Background: The purpose of this study is to compare the effectiveness of endoscopic release of the recurrent branch from surrounding soft tissue in combination with standard endoscopic carpal tunnel release (ECTR) surgery to standard ECTR surgery alone in patients with established abductor pollicis brevis (APB) muscle weakness. Methods: Using propensity score matching, we compared the recovery rates of postoperative clinical symptoms in patients with idiopathic carpal tunnel syndrome in whom the preoperative Medical Research Council (MRC) scale of the APB muscle (MRC-APB) was zero (no contraction) and with undetectable distal motor latency (DML) of APB, to those who underwent standard ECTR surgery alone and those who underwent recurrent branch release in addition to standard ECTR. Results: Forty-nine hands in the recurrent branch release group and 49 hands in the standard ECTR surgery group were extracted. There were statistically significant differences in postoperative recovery rate from MRC-APB 0 to '4 or 5' at 30 months (OR: 2.42; 95% CI: 1.03-5.67; p = 0.04) and at final follow-up (OR: 2.64; 95% CI: 1.11-6.26; p = 0.03). There were statistically significant differences in postoperative recovery of MRC-APB scales at 24 months (p = 0.03), 30 months (p = 0.02) and at final follow-up (p = 0.02). There were statistically significant differences in postoperative recovery of DML (p = 0.04). Conclusions: Endoscopic release of the recurrent branch in combination with standard ECTR surgery showed better recovery rates in MRC-APB and DML recovery compared to standard ECTR surgery alone. Level of Evidence: Level III (Therapeutic).

The Utility of the Carpal Tunnel Syndrome-6 for Predicting the Outcomes of Carpal Tunnel Release

PURPOSE

Considering the cost of, discomfort with, and time required for nerve conduction testing, the Carpal Tunnel Syndrome-6 (CTS-6) is often used to determine the likelihood of the presence of carpal tunnel syndrome. We sought to determine whether the CTS-6, designed as a diagnostic instrument, could serve a dual purpose and predict the outcome of carpal tunnel release (CTR) based on postoperative changes in the Boston Carpal Tunnel Questionnaire (BCTQ) score.

METHODS

This prospective observational study enrolled 118 adults before they underwent open CTR at a tertiary center. A primary regression analysis was used to determine the association between preoperative CTS-6 scores and changes in the BCTQ score at ≥6 months after surgery. Additional demographic, social, electrodiagnostic, and mental health variables were assessed for associations with changes in the BCTQ score. The secondary outcomes included single questions rating satisfaction with the result of CTR as well as symptom changes and the Decision Regret Scale. Noneffective CTR was defined as a BCTQ score change of <1.0 point or reported dissatisfaction.

RESULTS

Postoperatively, the BCTQ score improvement averaged 1.38 ± 0.77. Although 102 of 109 patients (94%) noted symptom improvement, 94 of 109 (86%) were satisfied with the result of CTR, and 78 of 109 patients (72%) demonstrated a meaningful change in the BCTQ score. Preoperative CTS-6 scores were not correlated with changes in BCTQ scores. CTS-6 scores were not associated with Decision Regret Scale scores, reported satisfaction, or the single-question assessment of symptom changes. Satisfaction, decision regret, and the single symptom change question were correlated with changes in the BCTQ score and each other. Dissatisfied patients were distinguished by a differential improvement in the BCTQ score (1.5 vs 0.7), but no preoperative variable consistently predicted noneffective CTR.

CONCLUSIONS

The CTS-6 score does not predict changes in BCTQ scores after CTR. Patient satisfaction with surgical results is associated with postoperative changes in carpal tunnel symptoms but is not predictable using preoperative information. A single question of symptom change may offer an efficient assessment of CTR outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Prevalência de variações anatômicas encontradas em pacientes com síndrome do túnel do carpo submetidos a liberação cirúrgica por via aberta clássica

Objective  To evaluate the prevalence of anatomical variations encountered in patients with carpal tunnel syndrome who underwent carpal tunnel classical open release.

Methods  A total of 115 patients with a high probability of clinical diagnosis for carpal tunnel syndrome and indication for surgical treatment were included. These patients underwent electroneuromyography and ultrasound for diagnostic confirmation. They underwent surgical treatment by carpal tunnel classical open release, in which a complete inventory of the surgical wound was performed in the search and visualization of anatomical variations intra- and extra-carpal tunnel.

Results  The total prevalence of anatomical variations intra- and extra-carpal tunnel found in this study was 63.5% (95% confidence interval [CI]: 54.5–72.4). The prevalence of the carpal transverse muscle was 57.4% (95% CI: 47.8–66.6%), of the bifid median nerve associated with the persistent median artery was 1.7% (95% CI: 0.0–4.2%), and the median bifid nerve associated with the persistent median artery and the transverse carpal muscle was 1.7% (95% CI: 0.0–4.2%).

Conclusion  The most prevalent extra-carpal tunnel anatomical variation was carpal transverse muscle. The most prevalent intra-carpal tunnel anatomical variation was median bifid nerve associated with the persistent median artery. The surgical finding of an extra-carpal tunnel anatomical variation, such as the transverse carpal muscle, may indicate the presence of other associated carpal intra tunnel anatomical variations, such as the bifid median nerve, persistent median artery, and anatomical variations of the recurrent median nerve branch.

Long-term Outcome of Local Steroid Injections Versus Surgery in Carpal Tunnel Syndrome: Observational Extension of a Randomized Clinical Trial

Background: In a previous paper, we have demonstrated that: (1) local injection of corticosteroids for carpal tunnel syndrome (CTS) is as effective as decompressive surgery, at 1-year follow-up; and (2) surgery has an additional benefit in the 2-year follow-up. In this study, we assess the long-term outcomes of both therapies in an observational extension of the patients originally enrolled in our randomized clinical trial. Methods: Patients were included in an open, randomized clinical trial, comparing injections versus surgery in CTS. After the end of the clinical trial, patients received the treatment prescribed by their general practitioner or specialist. Therapeutic failure was defined as the need of any new therapeutic intervention on the involved wrist. Comparison between groups was made using Cox multiple regression analysis. Estimation of the accumulated incidence of new therapeutic failure was made considering the withdrawal as a competitive risk (Gooley's test). Results: Of 163 randomized wrists at the beginning of the study, only 148 were available at the final follow-up. The mean follow-up was 6.3 and the median was 5.9 years. In the long-term follow-up, the accumulated incidence of therapeutic failure in the surgery group was 11.6% versus 41.8% in the injection group. The Cox multiple regression analysis showed a risk of failure associated with injection group of 4.5 (95% confidence interval [CI], 2.1-9.8; P < .0001). Conclusions: In long-term follow-up, surgery seems more effective than local corticosteroid injections in primary CTS. Nonetheless, about 58% of the patients in the injection group will not need further therapeutic interventions during the follow-up.

The Effectiveness of Hydrodissection with 5% Dextrose for Persistent and Recurrent Carpal Tunnel Syndrome: A Retrospective Study

Patients with failure of primary surgery for carpal tunnel syndrome (CTS) present a frustrating clinical problem because there are no relevant treatment guidelines, and the effect of current conservative management or revision surgery is unsatisfactory. Hydrodissection with 5% dextrose is emerging as an effective treatment for primary CTS and may be an effective alternative treatment method for persistent or recurrent post-surgical CTS. We retrospectively investigated the long-term effectiveness of hydrodissection with 5% dextrose for persistent or recurrent CTS. Thirty-six of forty consecutively-treated patients with either persistent or recurrent symptoms of CTS after surgery, who were treated with ultrasound-guided hydrodissection of the median nerve using 10 mL of 5% dextrose, were available to provide outcome data by a structured phone interview at least six months after treatment completion. Symptom relief ≥ 50% represented an effective outcome, while symptom relief < 50% was rated as a poor outcome. Nearly 2/3 (61.1%) of patients reported an effective outcome after a mean of 3.1 injections, with a post-injection follow-up mean of 33 (6−67) months. A non-significant trend toward a more frequently-effective outcome was observed in those with recurrent versus persistent symptoms following CTS (76.9% vs. 52.2%, p = 0.165). However, a significantly higher percentage of those with recurrent symptoms reported an excellent outcome, defined as a greater than 70% improvement (8/13 [61.6%] vs. 3/23 [13%], p = 0.006). The percentage of patients achieving an effective outcome was not significantly different between <2, 2−4, and >4 years of post-treatment follow-up (36.4% vs. 77.8% vs. 57.1%; p = 0.077). Hydrodissection with 5% dextrose may result in a clinically important and durable benefit in those experiencing persistent or recurrent CTS after surgery.

Carpal tunnel syndrome: Does preoperative disease severity influence the outcome of mini-open surgery?

In the practice of carpal tunnel surgery, open decompression of the median nerve in carpal tunnel syndrome (CTS) is recognized as the therapeutic priority. However, the speed and completeness of postoperative recovery of sensitivity and function depend on the initial clinical manifestations of the disease and the severity of the electrophysiological disorder. The aim of this study was to investigate the influence of preoperative clinical and electrophysiological factors on the outcome of surgical treatment of patients with CTS of varying severity. One-hundred and eighty-nine open decompressions of the median nerve via a mini-open incision were performed in 161 patients with idiopathic CTS. Clinical observations were classified in 5 groups, according to severity. Treatment results were evaluated per group at 6 weeks and 3, 6 and 12 months after surgery. In all cases, there was improvement and positive dynamics according to clinical and electroneuromyographic data. Open decompression of the median nerve via mini-open incision can achieve significant clinical and functional improvement in the majority of patients with CTS. However, the most favorable results were mainly seen in patients with initial severity classified in the first, second and third (lower severity) groups.

Self-Reliance and Postoperative Hand Recovery After Simultaneous, Bilateral Endoscopic Carpal Tunnel Release: A Prospective Study

PURPOSE

Outcomes and recovery of endoscopic carpal tunnel release (ECTR) have been broadly examined in studies. The total recovery time can potentially be reduced by performing simultaneous, bilateral ECTR. In this study we prospectively investigated days to self-reliance. As secondary outcomes, we investigated direct postoperative recovery of hand function and pre and postoperative symptom severity after simultaneous, bilateral ECTR.

METHODS

In this single-center prospective case series, we included all patients willing to participate after undergoing bilateral ECTR between December 2015 and July 2019. Every patient recorded days to self-reliance (when a patient could perform basic activities of daily living without the need for assistance from another person) and completed a preoperative and postoperative Boston Carpal Tunnel Questionnaire (BCTQ) evaluating postoperative hand function and pre and postoperative symptom severity.

RESULTS

In total, 81 patients received simultaneous, bilateral ECTR. Median days until self-reliance was 4; mean number of days was 4.9. Concerning BCTQ scores, postoperative functional status increased significantly each day, and mean BCTQ score decreased gradually from intense difficulty to little difficulty in daily tasks over a period of 7 days. Preoperative BCTQ symptom severity showed significant improvement compared to postoperative symptoms, evolving from medium to slight symptoms.

CONCLUSIONS

Simultaneous, bilateral ECTR offers recovery to self-reliance in 4 to 5 days with a gradual and significant increase of hand function in the following postoperative days.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Demographic Disparities amongst Patients Receiving Carpal Tunnel Release: A Retrospective Review of 92,921 Patients

Despite strong evidence supporting the efficacy of surgical release for carpal tunnel syndrome (CTS), previous studies have suggested that surgery is not performed equally amongst races and sex. The purpose of this study was to investigate potential socioeconomic disparities in the surgical treatment for CTS.

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.

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.

Evaluation of PROMIS' Ability to Detect Immediate Postoperative Symptom Improvement Following Carpal Tunnel Release

PURPOSE

We sought to determine whether subjective clinical improvement immediately after carpal tunnel release (CTR) was captured by Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression.

METHODS

Between September 2018 and January 2020, patients presenting to a single academic medical center hand clinic were asked to complete PROMIS UE, PF, PI, and Depression computer adaptive tests. In addition, patients who had CTR were asked to answer the following at their first postoperative clinic visit: "Since my last clinic visit, my condition is: (1) much better; (2) mildly better; (3) no change; (4) mildly worse; (5) much worse." For each patient, the last clinic visit was the final preoperative visit. The PROMIS domain scores were compared before and after surgery using paired t tests. The percentage of patients subjectively reporting better symptoms was calculated.

RESULTS

A total of 156 patients fit our inclusion criteria. The average number of days between the final preoperative visit and CTR was 7 (range, 0-30), and the average number of days between CTR and the first postoperative visit was 9 (range, 3-21). A total of 116 patients (74%) reported their carpal tunnel syndrome was better at their first postoperative visit. However, PROMIS UE, PF, and PI scores were significantly worse at the first postoperative visit, although not at clinically appreciable levels. There was no statistical or clinical difference in PROMIS Depression scores from pre- to postoperative time points.

CONCLUSIONS

Nearly 75% of patients subjectively report their carpal tunnel syndrome is better at their first follow-up visit within 3 weeks of CTR; however, PROMIS does not capture this improvement.

CLINICAL RELEVANCE

Hand surgeons evaluating patients shortly following CTR should be aware of the potential limitation of PROMIS to accurately capture immediate postoperative clinical outcomes. Disease-specific Patient-Reported Outcome Measures, such as the Boston Carpal Tunnel Questionnaire, may be preferred during this immediate postoperative timeframe.

Use of conservative therapy before and after surgery for carpal tunnel syndrome

Background

Conservative therapies are typically offered to individuals who experience mild or intermittent symptoms of carpal tunnel syndrome (CTS) or postoperatively to subjects who have undergone carpal tunnel release. Although long-term studies report mostly positive results for carpal tunnel release, knowledge on the need for conservative treatments following surgery is scarce. The aim of this retrospective cohort study was to examine the use of conservative therapies before and after carpal tunnel releasing surgery.

Methods

Of 528 patients who underwent carpal tunnel release surgery in the study hospital during the study period, 259 provided sufficiently completed questionnaires (response rate 49 %). The patients completed a questionnaire battery including a sociodemographic, medical history and symptom questionnaire, the Boston Carpal Tunnel Syndrome Questionnaire, 6-item CTS symptoms scale and EuroQoL 5D. Frequencies of conservative therapies pre- and postoperatively were calculated. Association between Pain VAS and satisfaction with treatment were examined in patient groups according to the use of conservative therapies.

Results

Of all patients, 41 (16 %) reported receiving only preoperative, 18 (7 %) reported receiving only postoperative, 157 (60 %) reported receiving both pre- and postoperative conservative therapies and 43 (17 %) did not receive any therapies. Preoperative use of conservative therapies was more common in females than males (82 % vs. 64 %; p = 0.002), but postoperatively no significant gender difference was observed. The patients who received conservative therapies were younger than non-users in both the preoperative (median age 59 vs. 66; p < 0.001) and postoperative (59 vs. 66; p = 0.04) phases. The patients reported high satisfaction with their treatment and simultaneous improvement in Pain VAS scores. Those receiving conservative therapies only preoperatively reported the highest satisfaction.

Conclusions

While the use of conservative therapies decreased after surgery, a large proportion of the patients received these adjunct interventions. Patients reported high satisfaction with their treatment one year post surgery. Pain outcome seems to be closely related to satisfaction with treatment.

Level of Evidence

Level III.

Health-care providers' perspectives on factors influencing return-to-work after surgery for nontraumatic conditions of the upper extremity

STUDY DESIGN

This study is a descriptive survey.

INTRODUCTION

Health care providers (HCPs) are key stakeholders who facilitate workers' return to work (RTW) following upper extremity surgery. Hand therapists play a major role in this process, yet we do not know if and/or how their perspectives differ from other HCPs.

PURPOSE OF THE STUDY

This study examined HCPs' opinion on factors that influence RTW after surgery for nontraumatic upper extremity conditions and whether HCPs from different disciplines differed in their opinion.

METHODS

HCPs (occupational therapists, physiotherapists, hand therapists, exercise physiologists, psychologists, surgeons, and general practitioners) completed a survey rating 50 factors on a worker's ability to RTW. Each factor was scored using a 5-point Likert scale from "not" to "extremely" influential, which was later dichotomised. Agreement was indicated at 75%. The level of disagreement between disciplines was examined.

RESULTS

Respondents (n = 787) identified 20 factors being influential on RTW. They are (in order from highest to lowest) poor pain coping (the highest, >85% of respondents), postoperative psychological state, RTW self-efficacy, employer/supervisor's support, employer's unwillingness for job modification, recovery expectations, job satisfaction, suitable duties availability, whether the job can be modified, and mood disorder diagnosis. There was agreement that two factors do not influence RTW, gender, and preemployment medical assessment. There was disagreement (P < .05) between HCP disciplines on six factors (obesity, comorbidities, doctors' RTW recommendation, diagnosis, fitness, income). There were no consistent patterns with respect to which professions disagreed across all six factors. Hand therapists differed from the other disciplines for three of the factors including diagnosis, comorbidities, and doctor's recommendation for RTW.

DISCUSSION

The factors that stakeholders agreed as having the greatest influence were mainly related to the worker (pain and psychological factors) and the workplace and are amenable to RTW interventions.

CONCLUSION

Interventions facilitating RTW and future research should consider the factors identified by HCPs in this study.

Patient Mindset and the Success of Carpal Tunnel Release

BACKGROUND

Depression and pain catastrophizing are aspects of the patient's mindset that have been shown to be important in relation to the outcome of carpal tunnel release. However, other factors of the patient's mindset have been understudied, such as treatment expectations and illness perceptions. The aim of the present study was to investigate the influence of these mindset aspects on outcome of carpal tunnel release, in addition to psychological distress and pain catastrophizing.

METHODS

A total of 307 patients with carpal tunnel syndrome who visited outpatient hand surgery clinics and who completed online questionnaires regarding demographic and psychosocial characteristics and carpal tunnel syndrome severity were included. The patient mindset was measured with the Patient Health Questionnaire-4, the Pain Catastrophizing Scale, the Credibility Expectancy Questionnaire, and the Brief Illness Perception Questionnaire. Hierarchical linear regression models were used to examine the relation between self-reported severity 6 months after carpal tunnel release, as measured with the Boston Carpal Tunnel Questionnaire, and psychosocial aspects of mindset, adjusting for preoperative Boston Carpal Tunnel Questionnaire score, patient characteristics, and comorbidities.

RESULTS

Independent associations with better self-reported outcome were found for higher treatment expectations (β = -0.202; p < 0.001) and illness comprehensibility (β = -0.223; p < 0.001). The additional explained variance in Boston Carpal Tunnel Questionnaire scores by the patient's mindset was 13.2 percent (psychological distress and pain catastrophizing together, 2.1 percent; treatment expectations and illness perceptions together, 11.1 percent).

CONCLUSION

Treatment outcome expectations and comprehensibility of illness are both independently associated with the outcome of carpal tunnel release, showing the importance of these aspects of the patient's mindset for the outcome of carpal tunnel release.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Sickness absence after carpal tunnel release: a multicentre prospective cohort study

OBJECTIVES

To describe when patients return to different types of work after elective carpal tunnel release (CTR) surgery and identify the factors associated with the duration of sickness absence.

DESIGN

Multicentre prospective observational cohort study.

SETTING AND PARTICIPANTS

Participants were recruited preoperatively from 16 UK centres and clinical, occupational and demographic information were collected. Participants completed a weekly diary and questionnaires at four and 12 weeks postoperatively.

OUTCOMES

The main outcome was duration of work absence from date of surgery to date of first return to work.

RESULTS

254 participants were enrolled in the study and 201 provided the follow-up data. Median duration of sickness absence was 20 days (range 1-99). Earlier return to work was associated with having surgery in primary care and a self-reported work role involving more than 4 hours of daily computer use. Being female and entitlement to more than a month of paid sick leave were both associated with longer work absences. The duration of work absence was strongly associated with the expected duration of leave, as reported by participants before surgery. Earlier return to work was not associated with poorer clinical outcomes reported 12 weeks after CTR.

CONCLUSIONS

There was wide variation in the duration of work absence after CTR across all occupational categories. A combination of occupational, demographic and clinical factors was associated with the duration of work absence, illustrating the complexity of return to work decision making. However, preoperative expectations were strongly associated with the actual duration of leave. We found no evidence that earlier return to work was harmful. Clear, consistent advice from clinicians preoperatively setting expectations of a prompt return to work could reduce unnecessary sickness absence after CTR. To enable this, clinicians need evidence-informed guidance about appropriate timescales for the safe return to different types of work.

Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial

OBJECTIVE

No study to our knowledge has investigated the effects longer than 1 year of manual therapy in carpal tunnel syndrome (CTS). The purpose of this study was to investigate the effects of manual therapy versus surgery at 4-year follow-up and to compare the post-study surgery rate in CTS.

METHODS

This randomized controlled trial was conducted in a tertiary public hospital and included 120 women with CTS who were randomly allocated to manual therapy or surgery. The participants received 3 sessions of physical therapy, including desensitization maneuvers of the central nervous system or carpal tunnel release combined with a tendon/nerve gliding exercise program at home. Primary outcome was pain intensity (mean and the worst pain). Secondary outcomes included functional status, symptom severity, and self-perceived improvement measured using a global rating of change scale. Outcomes for this analysis were assessed at baseline, 1 year, and 4 years. The rate of surgical intervention received by each group was assessed throughout the study.

RESULTS

At 4 years, 97 (81%) women completed the study. Between-group changes for all outcomes were not significantly different at 1 year (mean pain: mean difference [MD] = -0.3, 95% CI = -0.9 to 0.3; worst pain: MD = -1.2, 95% CI = -3.6 to 1.2; function: MD = -0.1, 95% CI = -0.4 to 0.2; symptom severity: MD = -0.1, 95% CI = -0.3 to 0.1) and 4 years (mean pain: MD = 0.1, 95% CI = -0.2 to 0.4; worst pain: MD = 0.2, 95% CI = -0.8 to 1.2; function: MD = 0.1, 95% CI = -0.1 to 0.3; symptom severity: MD = 0.2, 95% CI = -0.2 to 0.6). Self-perceived improvement was also similar in both groups. No between-group differences (15% physical therapy vs 13% surgery) in surgery rate were observed during the 4 years.

CONCLUSIONS

In the long term, manual therapy, including desensitization maneuvers of the central nervous system, resulted in similar outcomes and similar surgery rates compared with surgery in women with CTS. Both interventions were combined with a tendon/nerve gliding exercise program at home.

IMPACT

This is the first study to our knowledge to report clinical outcomes and surgical rates during a 4-year follow-up and will inform decisions regarding surgical versus conservative management of CTS.

LAY SUMMARY

Women with CTS may receive similar benefit from a more conservative treatment-manual therapy-as they would from surgery.

Fatores de insucesso do tratamento cirúrgico da síndrome do túnel do carpo: Quando e como revisar a cirurgia de descompressão do túnel do carpo

Despite being a procedure widely used all over the world with high rates of symptom remission, surgical treatment of carpal tunnel syndrome may present unsatisfactory outcomes. Such outcomes may be manifested clinically by non-remission of symptoms, remission of symptoms with recurrence a time after surgery or appearance of different symptoms after surgery. Different factors are related to this unsuccessful surgical treatment of carpal tunnel syndrome. Prevention can be achieved through a thorough preoperative clinical evaluation of the patient. As such, the surgeon will be able to make differential or concomitant diagnoses, as well as determine factors related to patient dissatisfaction. Perioperative factors include the correct identification of anatomical structures for complete median nerve decompression. Numerous procedures have been described for managing postoperative factors. Among them, the most common is adhesion around the median nerve, which has been treated with relative success using different vascularized flaps or autologous or homologous tissue coverage. The approach to cases with unsuccessful surgical treatment of carpal tunnel syndrome is discussed in more detail in the text.

Understanding central sensitization for advances in management of carpal tunnel syndrome

Carpal tunnel syndrome is the most common nerve compression disorder of the upper extremity, and it is traditionally considered a peripheral neuropathy associated with a localized compression of the median nerve just at the level of the carpal tunnel. Surgery and physiotherapy are treatment approaches commonly used for this condition; however, conflicting clinical outcomes suggest that carpal tunnel syndrome may be more complex. There is evidence supporting the role of peripheral nociception from the median nerve in carpal tunnel syndrome; however, emerging evidence also suggests a potential role of central sensitization. The presence of spreading pain symptoms (e.g. proximal pain), widespread sensory changes, or bilateral motor control impairments in people presenting with strictly unilateral sensory symptoms supports the presence of spinal cord changes. Interestingly, bilateral sensory and motor changes are not directly associated with electrodiagnostic findings. Other studies have also reported that patients presenting with carpal tunnel syndrome exhibit neuroplastic brainstem change supporting central sensitization. Current data would support the presence of a central sensitization process, mediated by the peripheral drive originating in the compression of the median nerve, in people with carpal tunnel syndrome. The presence of altered nociceptive gain processing should be considered in the treatment of carpal tunnel syndrome by integrating therapeutic approaches aiming to modulate long-lasting nociceptive barrage into the central nervous system (peripheral drive) and strategies aiming to activate endogenous pain networks (central drive).

Endoscopic Carpal Tunnel Release

Carpal tunnel syndrome represents compression of the median nerve in the carpal tunnel, which is defined by the carpal bones on the lateral, medial, and dorsal aspects and the transverse carpal ligament on the anterior aspect.¹ Symptoms of carpal tunnel syndrome include paresthesia, anesthesia, paresis, and pain located in the median nerve distribution. In severe cases, there may be atrophy of median nerve-innervated thenar muscles. In the United States, carpal tunnel syndrome affects approximately 3.72% of the population.² Conservative measures, such as bracing, steroid injections, and physical and occupational therapy, are commonly employed.¹ However, many patients still require more definitive surgical management, which may be in the form of open or endoscopic procedures. Regardless of surgical approach, the clinical success rates of carpal tunnel release have been reported to be 75%-90%.³ Recurrence rates are 8.4%-15% over 4-5 years,^4,5 with the lower end of this range representing the Agee single-portal technique. Endoscopic carpal tunnel release leads to reduced postoperative pain and an increase in transient neurologic deficits; however, no improvements have been reported in overall complication rate, subjective satisfaction, return to work, postoperative grip and pinch strength, and operative time.⁶ In this technical video, we present a case of single-incision endoscopic carpal tunnel release in a patient with severe symptoms after conservative measures failed. The patient experienced a noncomplicated postoperative course and demonstrated an excellent recovery at follow-up visits. Surgical decompression is an important treatment for refractory carpal tunnel syndrome, and videos such as this provide guidance for safe and effective treatment (Video 1).

Round Acupuncture for the Treatment of Recurrent Carpal Tunnel Syndrome

Objectives

Round Acupuncture having blunt end has developed from acupotomy. This case report is to find out that Round Acupuncture is effective in treating patients with recurrent carpal tunnel syndrome (CTS), which has not improved by steroid injection or acupotomy.

Methods

Round Acupuncture was inserted into the distal fibers of transverse carpal ligament and released toward the proximal fibers. Treatment was performed three times in total. T ingling, numbn ess, night pain and swelling sensation were assessed, and provocative maneuvers were also used.

Results

After treat ment, all symptoms completely disappeared and the patient had no recurrence until 3 months after treatment.

Conclusion

Round Acupuncture co uld be an effective treatment for recurrent CTS.

Carpal tunnel surgery: predictors of clinical outcomes and patients' satisfaction

Background

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy. Moreover, carpal tunnel release (CTR) surgery generally has excellent results. The present study aimed to investigate the predictors of clinical outcomes and satisfaction in patients with CTR.

Methods

In this observational prospective cohort study, 152 patients with open carpal tunnel release surgery were investigated. Complete clinical examinations were performed and recorded before the surgery, two weeks after the surgery and 6 months after the surgery. The Boston Carpal Tunnel Questionnaire (BCTQ) were assessed on admission and at last follow-up visits to evaluate clinical outcomes. Patients’ satisfaction was determined by a 10-point verbal descriptor nominal scale (1 = very poor, 5 = fair and 10 = excellent) and recorded during the last follow -up visits.

Results

Among 152 patients who were investigated, there were 118 (77.6%) females and 34 (22.36%) males. Overall, surgery improved the outcomes based on Symptom Severity Scale (SSS) and Functional Status Scale (FSS) (P < 0.05). Most of the considered variables did not show significant effects on clinical outcomes and patients’ satisfaction. However, duration of symptoms and electrophysiological severity were the predictors of the change score in SSS(P < 0.05). As well as, age was the only predictor of the change score in FSS (P < 0.05). Finally, according to the linear regression model, the pre-operative grip strength and age were the independent predictors of post-operative satisfaction (P < 0.05).

Conclusions

Results of the present study revealed that there was a significant improvement in clinical outcomes after CTS surgery. Stronger pre-operative grip strength and younger age were independent predictors of higher post-operative satisfaction. These results can be used in pre-operative counseling and management of post-operative expectations.

Management of Recalcitrant Carpal Tunnel Syndrome

Recalcitrant carpal tunnel syndrome presents a clinical challenge. Potential etiologies of persistent or recurrent symptoms after primary carpal tunnel release include incomplete nerve decompression, secondary sites of nerve compression, unrecognized anatomic variations, irreversible nerve pathology associated with chronic compression neuropathy, perineural adhesions, conditions associated with secondary nerve compression, iatrogenic nerve injury, or inaccurate preoperative diagnosis. Understanding the pertinent surgical anatomy and pathophysiology is essential toward developing an effective diagnostic and treatment strategy. A thorough clinical history and examination guide a comprehensive diagnostic evaluation that includes serial examinations, neurophysiologic testing, and imaging studies. Conservative treatment may provide symptomatic relief; however, surgical management involving revision neuroplasty, neurolysis, nerve reconstruction, and/or local soft-tissue flap augmentation may be indicated in refractory cases.

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

BACKGROUND

The effectiveness of the surgical treatment of carpal tunnel syndrome (CTS) is well known on short term. However, limited data is available about long-term outcome after carpal tunnel release (CTR). The aims of this study were to explore the long-term outcome after CTR and to identify prognostic factors for long-term outcome.

METHODS

Patients with clinically defined CTS underwent CTR and completed the Boston Carpal Tunnel Questionnaire at baseline (T₀), at about 8 months (T₁), and after a median follow-up of 9 years (T₂), as well as a 6-point scale for perceived improvement (at T₁ and T₂). Potentially prognostic factors were identified by logistic regression analysis and correlation.

RESULTS

At long-term follow-up, 87 patients (40.3%) completed the questionnaires. Mean score on Symptom Severity Scale (2.87 to 1.54; p < 0.001) and Functional Status Scale (2.14 to 1.51; p < 0.001) improved at 8 months and did not change significantly after 8 months. A favorable outcome was reported in 81.6%. A good treatment outcome after 8 months and to a lesser extent a lower FSS score at T₀ were associated with a better long-term outcome.

CONCLUSIONS

CTR is a robust treatment for CTS and its effect persists after a period of 9 years. The most important factor associated with long-term outcome is treatment outcome after about 8 months and to a lesser extent functional complaints preoperatively. Outcome is independent of patient characteristics, electrodiagnostic test results, or findings at the initial neurological examination.

Minimal clinically important difference for the Boston Carpal Tunnel Questionnaire: new insights and review of literature

No consensus exists about the minimal clinically important difference for the Boston Carpal Tunnel Questionnaire, which hampers its clinical application. This study assessed the minimal clinically important difference of this questionnaire. The Boston Carpal Tunnel Questionnaire was completed by 180 patients, with clinically defined carpal tunnel syndrome, preoperatively and at about 8 months follow-up after carpal tunnel release, together with a six-point scale for perceived improvement. Receiver operator characteristics curves showed that relative changes in Symptom Severity Scale and Functional Status Scale scores correspond better to a clinically relevant improvement than absolute changes. The minimal clinically important difference should be individually calculated from baseline Symptom Severity Scale and Functional Status Scale scores, as patients experiencing more symptoms require more improvement to notice a clinically important difference. By taking this into account, the Boston Carpal Tunnel Questionnaire is more meaningful as an outcome measure in research and clinical practice.

Functional Outcomes of 300 Carpal Tunnel Release: 1.5 cm Longitudinal Mini-incision

Objective

There is an opportunity for median nerve decompression by open surgery in carpal tunnel syndrome which is the most common surgical procedure in neurosurgical practice. The aim of this study is to evaluate the long-term outcomes of carpal tunnel release with 1.5 cm longitudinal mini-incision technique with regarding the effectiveness and safety.

Methods

For this prospective study, 300 hands for 188 patients with advanced carpal tunnel syndrome who had indication for neurolysis underwent carpal tunnel release through a 1.5 cm longitudinal mini-incision between March 2011 and 2015. There were 132 (70%) females and 56 (30%) males with a mean age of 40 ± 29.5 years (ranging from 24 to 73) and female to male: About 2.56.178 operations were performed for the right hand and 122 for the left hand. Preoperatively, all patients were evaluated with clinical examination and nerve conduction studies. The clinical effects of the patients assessed with the Global Symptom Score (GSS) and Visual Analog Patient Satisfaction Scale.

Results

The mean follow-up period was 18.6 ± 9.3 months (12-30 months). Postoperatively, 2% (six hands) complained of residual mild pain with tenderness of scar and only 1% (three hands) complained of median nerve damage (neuropraxy) with tingling and numbness but was temporary which improved after 1 week. Five patients (seven hands) loosed strength of their wrists, but muscle force of abductor pollicis brevis reinforced after 1 month. There is no evidence of local infection, stiffness, loss of some wrist strength, or recurrence of the disorder. Postoperative GSS scoring obviously improved than preoperative (P < 0.002). There is no patient who underwent reoperation. The mean time recovery appeared almost 2 weeks.

Conclusion

1.5 cm longitudinal mini-incision method in carpal tunnel syndrome decompression showed satisfactory pain relief, wound healing, and nontender scar with good functional outcomes. The technique was performed safely without major complication.

Treatment of Recurrent and Persistent Carpal Tunnel Syndrome: The Fasciocutaneous Dorsal Ulnar Artery Flap

Surgical treatment of recurrent and persistent carpal tunnel syndrome by repeat carpal tunnel release combined with soft tissue nerve coverage results in a higher success rate for symptomatic relief in the presence of a scarred median nerve. Several techniques, including local pedicled flaps, transposition flaps from the distal forearm, and free flaps, have been described, but consensus regarding a preferred technique has not been reached. The dorsal ulnar artery flap or Becker flap is a local fasciocutaneous flap based on a dorsal perforating branch of the ulnar artery that can be used for soft tissue coverage of the median nerve. Advantages of this technique are the quick and easy dissection and low donor site morbidity. Studies of its use for the treatment of recurrent carpal tunnel syndrome are limited.

Economic benefit of carpal tunnel release in the Medicare patient population

OBJECTIVE The epidemiology of carpal tunnel syndrome (CTS) has been extensively researched. However, data describing the economic burden of CTS is limited. The purpose of this study was to quantify the disease burden of CTS and determine the economic benefit of its surgical management. METHODS The authors utilized the PearlDiver database to identify the number of individuals with CTS in the Medicare patient population, and then utilized CPT codes to identify which individuals underwent surgical management. These data were used to calculate the total number of disability-adjusted life years (DALYs) associated with CTS. A human capital approach was employed and gross national income per capita was used to calculate the economic burden. RESULTS From 2005 to 2012 there were 1,500,603 individuals identified in the Medicare patient population with the diagnosis of CTS. Without conservative or surgical management, this results in 804,113 DALYs without age weighting and discounting, and 450,235 DALYs with age weighting and a discount rate of 3%. This amounts to between $21.8 and $39 billion in total economic burden, or $2.7-$4.8 billion per year. Surgical management of CTS has resulted in the aversion of 173,000-309,000 DALYs. This has yielded between $780 million and $1.6 billion in economic benefit per year. Endoscopic carpal tunnel release provided between $11,683 and $23,186 per patient at 100% success while open carpal tunnel release provided between $10,711 and $22,132 per patient at 100% success. The benefit-cost ratio at its most conservative is 2.7:1, yet could be as high as 6.9:1. CONCLUSIONS CTS is prevalent in the Medicare patient population, and is associated with a large amount of economic burden. The surgical management of CTS leads to a large reduction in this burden, yielding extraordinary economic benefit.

Long-Term Patient-Reported Outcomes After Surgery for Superior Canal Dehiscence Syndrome

OBJECTIVE

Evaluate the long-term patient-reported outcomes of surgery for superior canal dehiscence syndrome (SCDS).

STUDY DESIGN

Cross-sectional survey.

SETTING

Tertiary referral center.

PATIENTS

Adults who have undergone surgery for SCDS with at least 1 year since surgery.

MAIN OUTCOME MEASURE(S)

Primary outcome: change in symptoms that led to surgery.

SECONDARY OUTCOMES

change in 11 SCDS-associated symptoms, change in psychosocial metrics, and willingness to recommend surgery to friends with SCDS.

RESULTS

Ninety-three (43%) respondents completed the survey with mean (SD) time since surgery of 5.3 (3.6) years. Ninety-five percent of respondents reported the symptoms that led them to have surgery were "somewhat better," "much better," or "completely cured." Those with unilateral symptoms were more likely to report improvement than those with bilateral symptoms. There was no difference between those with short (1-5 yr) versus long (5-20 yr) follow-up. Each of the SCDS-associated symptoms showed significant improvement. The largest improvements were for autophony, pulsatile tinnitus, audible bodily sounds, and sensitivity to loud sound. Headaches, imbalance, dizziness, and brain fog showed the least improvements. Most patients reported improvements in quality of life, mood, and ability to function at work and socially. Ninety-five percent of patients would recommend SCDS surgery.

CONCLUSIONS

Respondents demonstrated durable improvements in the symptoms that led them to have surgery. Auditory symptoms had the greatest improvements. Headaches, imbalance, dizziness, and brain fog showed the least improvements. Nearly, all patients would recommend SCDS surgery to others. These results can be used to counsel patients regarding the lasting benefits of surgery for SCDS.

Effectiveness of ultrasonography and nerve conduction studies in the diagnosing of carpal tunnel syndrome: clinical trial on accuracy

BACKGROUND

The aim of this study was to evaluate the effectiveness of two diagnostic tests routinely used for diagnosing carpal tunnel syndrome (CTS)-ultrasonography (US) and nerve conduction studies (NCS)-by comparing their accuracy based on surgical results, with the remission of paresthesia as the reference standard.

METHODS

We enrolled 115 patients, all of the female gender with a high probability of a clinical diagnosis of CTS. All patients underwent US and NCS for a diagnosis and subsequent surgical treatment. As a primary outcome, the accuracy of the US and NCS diagnoses was measured by comparing their diagnoses compared with those determined by the surgical outcomes. Their accuracy was secondarily evaluated based on before and after scores of the Boston Carpal Tunnel Questionnaire (BCTQ).

RESULTS

Overall, 104 patients (90.4%) were diagnosed with CTS by the surgical reference standard, 97 (84.3%) by NCS, and 90 (78.3%) by US. The concordance of NCS and surgical treatment (p < 0.001; kappa = 0.648) was superior to that of US and surgical treatment (p < 0.001; kappa = 0.423). The sensitivity and specificity of US and NCS were similar (p = 1.000 and p = 0.152, respectively: McNemar's test). The BCTQ scores were lower after surgery in patients diagnosed by both US and NCS (p < 0.001and p < 0.001, respectively: analysis of variance).

CONCLUSIONS

US and NCS effectively diagnosed CTS with good sensitivity but were not effective enough to rule out a suspicion of CTS.

TRIAL REGISTRATION

This study was registered at September, 10 th, 2015, and the registration number was NCT02553811 .

Treatment outcome in patients with clinically defined carpal tunnel syndrome but normal electrodiagnostic test results: a randomized controlled trial

Little is known about treatment effect of carpal tunnel release in patients with clinically defined carpal tunnel syndrome (CTS), but normal electrodiagnostic test results (EDX). The aim of this study was to determine whether this category of patients will benefit from surgical treatment. 57 patients with clinically defined CTS and normal EDX were randomized for surgical treatment (n = 39) or non-surgical treatment (n = 18). A six-point scale for perceived improvement as well as the Boston Carpal Tunnel Questionnaire was completed at baseline and at follow-up after 6 months. A significant improvement of complaints was reported by 70.0% of the surgically treated patients and 39.4% reported full recovery 6 months after surgery. Furthermore, both Functional Status Score and Symptom Severity Score improved significantly more in the surgically treated group (p = 0.036 and p < 0.001, respectively). This study demonstrates that most patients with clinically defined CTS and normal EDX results will benefit from carpal tunnel release. Therefore, this group of CTS patients must not a priori be refrained from surgery.