A Prospective Assessment of Carpal Tunnel Surgery with Respect to Age

A Review of Carpal Tunnel Syndrome and Its Association with Age, Body Mass Index, Cardiovascular Risk Factors, Hand Dominance, and Sex

Carpal tunnel syndrome (CTS) is one of the most common compressive, canalicular neuropathies of the upper extremities, causing hand pain and impaired function. CTS results from compression or injury of the median nerve at the wrist within the confines of the carpal tunnel. Parameters such as age, sex, and body mass index (BMI) could be risk factors for CTS. This research work aimed to review the existing literature regarding the relationship between CTS and possible risk factors, such as age, sex, BMI, dominant hand, abdominal circumference, respiratory rate, blood pressure, and cardiac rate to determine which ones are the most influential, and therefore, take them into account in subsequent applied research in the manufacturing industry. We performed a literature search in the PubMed, EBSCO, and ScienceDirect databases using the following keywords: carpal tunnel syndrome AND (age OR sex OR BMI OR handedness OR abdominal circumference OR respiratory rate OR blood pressure OR cardiac rate). We chose 72 articles by analyzing the literature found based on selection criteria. We concluded that CTS is associated with age, female sex, and high BMI. Trends and future challenges have been proposed to delve into the relationship between risk factors and CTS, such as correlation studies on pain reduction, analysis of weight changes to predict the severity of this pathology, and its influence on clinical treatments.

Independent Variables Affecting Outcome of Carpal Tunnel Release Surgery

BACKGROUND

In making the decision to undergo carpal tunnel release (CTR), patients may consider probability of symptom resolution. Prior studies have examined potential preoperative variables that might influence the postoperative outcome. Few studies, however, contain the sample size, prospective design, and high participant completion rate to provide solid data from which to counsel patients. The purpose of this study was to prospectively evaluate factors that have been implicated or dismissed in past studies as sources of outcome variation following CTR surgery and provide patient-relatable facts that the surgeon might use in preoperative patient counseling.

METHODS

One thousand thirty-one consecutive patients undergoing open CTR were prospectively enrolled. Preoperative frequency of daytime numbness, nighttime awakening, and duration of symptoms were recorded in addition to physical exam, height, weight, gender, history of diabetes, history of thyroid disease, and severity of electrodiagnostic findings. After surgery, patients reported percent resolution of numbness at defined intervals.

RESULTS

Age and gender are the only independent factors that predict the degree of resolution of numbness 6 months following surgery. All other studied variables are not independent factors nor are any paired combinations of factors. Below the age of 50, the average reported resolution of daytime numbness by 6 months is 97.3% (men 91.8% and women 99.4%). After age 50, there is a linear 0.77% decline in average resolution of daytime numbness per year.

CONCLUSIONS

Age and gender but no other studied factors predict resolution of daytime numbness in a multivariate model of patients undergoing CTR.

Longitudinal Outcomes Following a Randomized Controlled Trial of Dynamic Splint Stretching for Carpal Tunnel Syndrome

Background: The incidence of carpal tunnel syndrome (CTS) is 48 million patients in the United States. The purpose of this longitudinal study was to determine whether Dynasplint stretching (immediately after diagnosis) had an effect on a patient's decision to seek surgical treatment for CTS. Methods: Fifty patients (10 men, 40 women, mean age 51.2 ± 12 years) were recruited for this randomized, controlled, longitudinal trial. Patients were diagnosed with CTS by physical examination and nerve conduction studies. The intervention used was Dynasplint stretching that delivered a prolonged duration of low load stretching. Patients who were randomly chosen for the Experimental category wore the device for two 30-minute sessions per day with regular increases in splint tension for 60 days. Control patients received nonsteroidal anti-inflammatory medication plus instructions on daily home stretching. Results: The final, longitudinal outcome showed a 72% reduction in surgery chosen by the experimental group (n = 25), compared with 38% reduction for control patients (n = 25). Conclusions: Immediate treatment with Dynasplint stretching showed a 2 to 1 reduction in surgery, with abundant financial savings.

Endoscopic release for severe carpal tunnel syndrome in octogenarians

PURPOSE

To investigate the clinical outcomes of endoscopic carpal tunnel release for severe carpal tunnel syndrome in octogenarians compared with a younger cohort.

METHODS

Fifty-five hands in 48 patients were enrolled in this study. There were 27 hands in 24 octogenarians and 28 hands in 24 patients in a younger group with average ages of 83 and 60 years, respectively. Postoperative follow-ups were 8.5 and 7.2 months, respectively. Clinical evaluation included documentation of subjective symptoms and Semmes-Weinstein testing before surgery, 3 months after surgery, and at final follow-up. Symptom severity and function outcomes scores and compound muscle action potential of abductor pollicis brevis as an electrophysiological assessment were evaluated before surgery and at the final follow-up.

RESULTS

Nocturnal pain and paresthesias were improved in all patients. The octogenarians had poorer recovery of Semmes-Weinstein testing score and better improvement of outcomes scores than the younger group. There was no difference of the results in postoperative electrophysiological improvement between the groups.

CONCLUSIONS

Endoscopic release for severe carpal tunnel syndrome relieved symptoms and improved activities of daily living in octogenarians.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Carpal tunnel decompression in the super-elderly

There is conflicting evidence about the functional outcome and rate of satisfaction of super-elderly patients (≥ 80 years of age) after carpal tunnel decompression.

We compiled outcome data for 756 patients who underwent a carpal tunnel decompression over an eight-year study period, 97 of whom were super-elderly, and 659 patients who formed a younger control group (< 80 years old). There was no significant difference between the super-elderly patients and the younger control group in terms of functional outcome according to the mean (0 to 100) QuickDASH score (adjusted mean difference at one year 1.8; 95% confidence interval (CI) -3.4 to 7.0) and satisfaction rate (odds ratio (OR) 0.78; 95% CI 0.34 to 1.58). Super-elderly patients were, however, more likely to have thenar muscle atrophy at presentation (OR 9.2, 95% CI 5.8 to 14.6). When nerve conduction studies were obtained, super-elderly patients were more likely to have a severe conduction deficit (OR 12.4, 95% CI 3.0 to 51.3).

Super-elderly patients report functional outcome and satisfaction rates equal to those of their younger counterparts. They are more likely to have thenar muscle atrophy and a severe nerve conduction deficit at presentation, and may therefore warrant earlier decompression.

Cite this article: Bone Joint J 2014; 96-B:1234–8.

OUTCOMES OF OPEN CARPAL TUNNEL RELEASES AND ITS PREDICTORS: A PROSPECTIVE STUDY

A prospective study of 74 patients who underwent open carpal tunnel releases was conducted, with a follow-up period of six months. We analyzed multiple preoperative variables in order to identify factors that might predict outcomes. These outcomes included improvement in symptom severity and functional severity scores, grip strength as well as patient satisfaction. All the patients showed improvement in symptoms with 72% showing complete symptomatic relief, 74% showing improvement in function and 66% showing improvement in grip strength, and 82% were either completely or very satisfied with the results of surgery. Older patients and patients with weakness were associated with poorer outcomes. Higher preoperative symptom severity and functional severity scores were also associated with less improvement in symptoms and function, respectively. This information would benefit the surgeons and patients during preoperative counseling and help facilitate the decision-making process for both parties.

A 6-year outcome of patients who cancelled carpal tunnel surgery

The long-term outcomes of patients with carpal tunnel syndrome who were scheduled for release but did not proceed to surgery were compared to patients who underwent surgery, matched on preoperative symptom scores. Both groups completed the Levine-Katz questionnaire 6 years after enrolment to our multicentre carpal tunnel syndrome outcomes database. Symptom and function scores improved for the surgical (n = 24) and non-surgical (n = 36) groups (p < 0.001). Improvement in symptom scores was greater in surgical patients compared to non-surgical patients (n = 24 matched pairs; p = 0.007) but improvement in function scores between groups was not significantly different (p = 0.13). For surgical patients, function and symptom scores improved by 6 months and were unchanged at 6 years. Patients planning surgical release can expect symptomatic and functional benefits within 6 months. Overall improvement was experienced by both groups, with a superior outcome achieved with surgery. The symptoms of carpal tunnel syndrome may improve without surgery, but further studies are needed to understand the natural history of the disorder.

Effect of age on subjective complaints and objective severity of carpal tunnel syndrome: prospective study

OBJECTIVES

Older patients with carpal tunnel syndrome who are resistant to conservative treatment often have a less than satisfactory outcome after surgery. We therefore investigated whether the age of the patient affects the subjective complaints or the objective severity of the nerve entrapment prior to surgery in patients younger than 40 years compared with those above 70 years of age.

DESIGN

Prospective study.

SETTING

NHS specialist neurophysiology department.

PARTICIPANTS

One hundred and six splint-resistant patients scored their subjective complaints and scores were then compared with the neurophysiology results.

MAIN OUTCOME MEASURES

Nerve conduction speeds and subjective visual analogue score of pain, sensation and motor function.

RESULTS

Conduction speeds were significantly more affected in patients over 70 years of age than in those under 40 years. Older patients scored their subjective complaints lower than younger patients.

CONCLUSIONS

Older patients' subjective complaints misrepresent the severity of the nerve entrapment. Clinicians should have a lower threshold for objective investigation of patients older than 70 years of age to minimize development of irreversible nerve damage.

Clinical outcome of carpal tunnel release with and without opposition transfer

We studied the clinical outcome in 24 patients (25 hands) with carpal tunnel syndrome characterized by severe thenar muscle atrophy, who were treated by open carpal tunnel release alone (10 hands) or with simultaneous opposition transfer (15 hands). We also compared the surgical results in patients younger or older than 65 years. Pain and numbness improved after open carpal tunnel release but more so in younger patients. Activities of daily living also improved with and without opposition transfer; however, certain activities such as fastening hooks or buttons, using chopsticks and turning a key in a lock improved more with opposition transfer. Grip strength did not improve, with or without opposition transfer, regardless of the patients' ages. Pinch strength improved more with opposition transfer.

High incidence of absent nerve conduction in older patients with bilateral carpal tunnel syndrome

INTRODUCTION

Carpal tunnel syndrome has been reported by some to have a less satisfactory outcome in older patients following surgery. However, this impression is not supported by other investigators but no objective explanation has been suggested for these differences. In our department, such patients are routinely treated with night wrist splints and, if this is unsatisfactory, they are investigated with nerve conduction studies prior to surgery.

PATIENTS AND METHODS

This paper reports the neurophysiological outcome in a young (< 40 years of age) and an older (> 60 years of age) group of patients with clinical bilateral carpal tunnel syndrome who did not benefit from splints.

RESULTS

The results showed that both the motor and sensory conduction speeds are significantly lower in the older age group. More importantly in the older group, half had one or more hands where the sensory conduction was absent. In four out of these 10 patients this finding was bilateral and three patients had unilateral absent motor conduction. In the younger group, no patient had absent conduction.

CONCLUSIONS

Poor surgical outcome in some older patients may be because of irreversibly damaged nerves prior to surgery and pre-operative neurophysiology is, therefore, recommended both for clinical and medicolegal reasons.

Endoscopic versus open carpal tunnel release

PURPOSE

This study compared endoscopic carpal tunnel release with the conventional open technique with respect to short- and long-term improvements in functional and clinical outcomes.

METHODS

We assessed 72 outpatients diagnosed with carpal tunnel syndrome. Of these patients, 37 underwent the endoscopic method according to Chow and 35 were assigned to the open method. Improvement in symptoms, severity, and functionality were evaluated at 2 days, 1 week, 2 weeks, and 1 year postoperatively. Changes in clinical outcomes were evaluated at 1 year postoperatively. Complications were also assessed.

RESULTS

Both groups showed similar improvement in all but 1 outcome 1 year after the release; increase in grip strength was significantly higher in the endoscopic group. However, the endoscopic method showed a greater improvement in symptoms and functional status compared with the open method at 2 days, 1 week, and 2 weeks postoperatively. Separate analysis of the questions referring to pain showed that the delay in improvement in the open group was because of the persistence of pain for a longer period. Paresthesias and numbness decrease immediately after the operation with comparable rates for both groups.

CONCLUSIONS

Endoscopic carpal tunnel release provides a faster recovery to operated patients for the first 2 weeks, with faster relief of pain and faster improvement in functional abilities. Paresthesia and numbness subside in an identical manner with the 2 techniques. At 1 year postoperatively, both open and endoscopic techniques seem to be equivalently efficient.

Are standardized patient self-reporting instruments applicable to the evaluation of ulnar neuropathy at the elbow?

BACKGROUND

This study attempts to confirm that the Disabilities of Arm, Shoulder and Hand (DASH) Outcome Measure self-administered questionnaire is valid specifically for ulnar neuropathy at the elbow. Validity of the Levine-Katz questionnaire for ulnar neuropathology compared with DASH was also studied.

MATERIALS AND METHODS

Forty-eight patients with isolated ulnar nerve surgery completed a 6-month evaluation. Patients were assigned a clinical stage. The DASH and Levine-Katz questionnaires were administered, and pinch and grip strength were measured preoperatively and postoperatively. Levine-Katz questionnaires were correlated with DASH to establish criterion validity. Construct validity was tested by determining a relationship between scores and clinical stages and by comparing scores preoperatively and postoperatively.

RESULTS

There was a high correlation between DASH scores and symptom severity and functional status. Although correlations were significant between DASH and biomechanical measures, correlation coefficients were lower. Postoperatively, all measures improved significantly.

CONCLUSION

This study confirms that scores on the DASH questionnaire reflect the clinical staging of ulnar neuropathy at the elbow.

Outcome of carpal tunnel decompression: the influence of age, gender, and occupation

The aim of this study was to investigate the effect of age, gender, and occupation on the outcome of carpal tunnel decompression. A total of 479 patients (342 females, 137 males) with a mean age of 56 years undergoing 608 carpal tunnel decompressions were prospectively studied. Outcome was assessed using the Brigham Hospital carpal tunnel questionnaire at two weeks pre-operatively and six months post-operatively. Cases were divided into four age categories (less than 40 years of age, 40-59, 60-79, and over 80 years of age) and two occupation (repetitive and non-repetitive) groups. The mean differences for both the symptom-severity and functional-status scores amongst the four age categories were similar and no significant difference was found. The mean differences for both the symptom-severity and functional-status scores between females and males and the two occupation groups were similar and no significant differences were found. The majority of the patient's symptoms improved following carpal tunnel decompression. However, we found no influence of age, gender, or occupation on the outcome of carpal tunnel decompression in our series of patients.

Lower touch sensibility in the extremities of healthy Indians: further deterioration with age

Touch sensibility testing is a cost-effective, psychophysical measure of peripheral nerve function and impairment. However, there is limited information regarding the natural variability in touch sensibility across different populations and different age groups. We studied 568 healthy Indian volunteers without any clinical evidence of peripheral nerve disease. Touch sensibility was evaluated bilaterally in palms, feet, and heels, using Semmes-Weinstein monofilaments, with target forces ranging from 0.008 to 300 g. No differences were observed between the right and the left limbs. The lowest target force detected ranged from 0.4 to 2 g in the palms and 1.4 to 15 g in the feet. These values showed further increase with age. Women compared with men had higher sensibility in the palms in most age groups. Touch sensibility thresholds recorded in a large group of Indians were higher than that reported in other populations. These findings have clinical implications for the diagnosis of early nerve impairment in the elderly and in disease states drawing attention to geographic variations in touch sensation.