Early Postoperative Improvement in Sleep and Pain After Carpal Tunnel Release

Carpal tunnel syndrome and sleep, a systematic review and meta-analysis

BACKGROUND

The most common symptom and reason patients seek treatment for carpal tunnel syndrome is lack of sleep. Our purpose was to determine how much sleep-related symptoms of carpal tunnel syndrome improve after carpal tunnel release using validated patient-reported outcome measures (PROMs) and objective sleep data as primary measures of interest.

METHODS

A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMed, Cochrane, and ClinicalTrials.gov. Only interventional clinical trials that examined primary outcome measures of interest were included. Patient-reported outcome measures underwent meta-analysis to determine how much scores improved following carpal tunnel release.

RESULTS

The Pittsburgh Sleep Quality Index improved significantly after carpal tunnel release, by 4.43 points and 6.02 points at 1-3 and 6-12 months postoperatively, respectively, and continued to improve up to 2 years. Improvement on the Insomnia Severity Index after carpal tunnel release was also significant, with improvement up to 1 year postoperatively, by 8.54 points and 9.05 points at 1-3 and 6-12 months, respectively. Insomnia Severity Index scores improved significantly after splinting as well.

CONCLUSIONS

The present meta-analysis determined to what extent patients can expect their sleep to improve after operative and non-operative intervention, as measured by various patient-reported outcome measures that assess sleep. The Pittsburgh Sleep Quality Index and Insomnia Severity Index correlated very well between studies and across hundreds of patients with carpal tunnel syndrome. Data are lacking to define the minimal clinically important difference and assess whether patients achieve a minimal clinically important difference for sleep questionnaires; more information on this topic is needed.

LEVEL OF EVIDENCE

III.

The Influence of Wound Closure Techniques after Surgical Decompression in Patients with Carpal Tunnel Syndrome on Sleep Disturbance and Life Quality: A Prospective Comparison of Surgical Techniques

BACKGROUND

The compression of the median nerve within the carpal tunnel is the cause of carpal tunnel syndrome (CTS). Surgical decompression is successful in improving sleep and quality of life, but the effect of tissue adhesives as a material for wound closure has not been investigated. The objective of the study was to evaluate sleep disorders and health-related life quality by comparing two methods for wound closure after carpal surgery in participants who were randomized to receive tissue adhesives or transcutaneous sutures.

METHODS

The subjects, aged 61.56 ± 12.03 years, were randomized to receive either tissue adhesives (n = 50) or suture-based wound closure (n = 50) using the Glubran Tiss 2® skin adhesive after subcutaneous running sutures. The outcomes were assessed during the 12-month postoperative follow-up. The Pittsburgh Sleep Quality Index (PQSI) and Insomnia Severity Scale (ISI) were used for the sleep disturbance assessment, and for the health-related quality of life assessment, the total SF-36 (36-Item Short Form Survey) was used.

RESULTS

The PQSI, ISI, and SF-36 were not statistically different between groups during the follow-up, except in the ISI score two weeks after surgery (9.40 ± 1.18 in the tissue adhesive group vs. 9.96 ± 1.09 in the suture-based group, p = 0.008). The PQSI, ISI, and SF-36 scores for all the subjects and groups were persistently improved at all the follow-up intervals after surgery. The total SF-36 score increased 12 months after surgery (49.84 ± 5.85 vs. 82.46 ± 5.68, p < 0.001).

CONCLUSIONS

Cyanoacrylate-based adhesion material can be used for wound closure after open CTS decompression as a standard transcutaneous suture, and both techniques equally lead to improved sleep and life quality. The possible advantages of tissue adhesives include a faster reduction in the ISI.

Validation of the Polish version of the Boston Carpal Tunnel Questionnaire, and the influence of treatment for disordered sleep and daytime sleepiness in carpal tunnel syndrome

Purpose

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, with paresthesias and pain in the hand and wrist. CTS is also associated with insomnia and excessive daytime sleepiness (EDS) resulting from the nocturnal exacerbation of symptoms. The Boston Carpal Tunnel Questionnaire (BCTQ) was developed for the assessment of therapeutic outcomes. It consists of two subscales: the Symptom Severity Scale (SSS) and the Functional Status Scale (FSS). The aim of this study was to perform an adaptation and validation of the Polish language version of BCTQ (pBCTQ). A second aim was to investigate the influence of treatment of CTS on insomnia and EDS.

Methods

The validation of the pBCTQ followed the widely accepted recommendations. In our consecutive sampling survey 130 patients with CTS filled out the pBCTQ, EQ-5D-5L quality of life questionnaire, the Athens Insomnia Scale (AIS) and the Epworth Sleepiness Scale (ESS). 26 of them filled out pBCTQ once again, two weeks later, and 35 filled out the pBCTQ and other items after therapy.

Results

The pBCTQ showed good internal consistency: 0.91 for SSS and 0.93 for FSS (Cronbach's α). The test-retest reliability showed an intraclass coefficient of 0.69 for SSS and 0.55 for FSS. Both subscales correlated also with nerve conduction studies (NCS) as well as with the EQ-5D-5L, AIS, and ESS. After therapy, both subscales and AIS significantly decreased. Improvement was also seen in the NCS and EQ-5D-5L, but not in the ESS.

Conclusions

The pBCTQ is a reliable, valid, and responsive tool for measuring the outcome of CTS. Therapy for CTS leads to the improvement of concurrent insomnia but may not change daytime sleepiness.

Outcomes of Patients with and without Nighttime Awakening Symptoms After Carpal Tunnel Release

Background: A common symptom associated with carpal tunnel syndrome (CTS) is nighttime awakening (NTA), which typically resolves quickly following carpal tunnel release (CTR). The early improvement in those who do not wake-up at night is less clear. This study investigates outcomes following CTR in patients with preoperative NTA symptoms compared to those without at 6 weeks and 3 months. Methods: Patients diagnosed with CTS who proceeded with CTR and agreed to participate in a prospective study completed the Boston Carpal Tunnel Questionnaire (BCTQ) and Michigan Hand Outcome Questionnaire (MHQ) at their preoperative appointment and 6-week and 3-month follow-ups. We compared outcomes between time points for improvement. Results: Of 45 patients, 37 patients with NTA had BCTQ scores of 3.09, 1.86, and 1.50 at preoperative, 6-week, and 3-month follow-up, respectively, and MHQ scores of 56.68, 74.91, and 81.01. NTA patients had improvement of both BCTQ and MHQ at 6 weeks and 3 months. Nonawakening patients had BCTQ scores of 2.58, 2.15, and 1.86 and MHQ scores of 57.94, 62.71, and 72.16, respectively. This cohort did not have significant improvement of MHQ at 6 weeks, but did at 3 months. The BCTQ severity scores in the nonawakening patients had significant improvement at both 6 weeks and 3 months, but did not at either time point for the BCTQ functionality scores. At 6 weeks, 2/37 patients continued to have NTA and no patients had NTA at 3 months. Conclusion: Patients with CTS and NTA symptoms had significant improvements in BCTQ and MHQ at 6 weeks and 3 months. Patients who did not awaken at night did not have significant improvements when evaluating BCTQ functional results, although they did improve when analyzing for BCTQ for symptom severity and MHQ, but not to the same level as those that do awaken and improvement was slower based on MHQ scores.

Improvement of Sleep Quality after Surgical Decompression in Carpal Tunnel Syndrome

Background Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy which can cause severe sleep disturbance. Carpal tunnel release (CTR) is a choice for severe cases, which has shown to improve sleep quality, but the available evidence is limited. This study aimed to investigate the impact of CTR on sleep quality and hand symptoms and functions in patients with CTS.

Methods This was a prospective study in 2019–2020 on patients with CTS and poor sleep quality undergoing CTR. Patients were evaluated before and at 1, 3, and 12 months after CTR by the Pittsburgh sleep quality index (PSQI) and Boston carpal tunnel syndrome questionnaires.

Results There were 33 patients with 27 females (82%) and a median age of 51 years. The median time of CTS diagnosis and having sleep disorder before CTR were 12 and 6 months, respectively. The outcomes significantly improved after CTR, with the median PSQI and Boston symptom and function scores reduced from 12, 33, and 23 before CTR to 9, 14, and 11 at 1 month; 7, 13, and 9 at 3 months; and 1, 11, and 8 at 12 months postoperatively, respectively. The correlations between the PSQI and Boston symptom and function scores were > 0.6 at all time-points.

Conclusions Surgical decompression significantly improves sleep quality and the hand symptoms and functions in patients with CTS. Long-term evaluations are lacking and thus are required in future studies.

Acute Pain Predictors of Remote Postoperative Pain Resolution After Hand Surgery

INTRODUCTION

Chronic postsurgical pain (CPSP) is a global issue with high prevalence. This study compared acute pain descriptors among patients undergoing carpal tunnel release (CTR) or trigger finger release (TFR). We hypothesized worst pain intensity on postoperative day (POD) 10 would be best to predict the time to pain resolution.

METHODS

In this secondary analysis of a negative, randomized, double-blind placebo-controlled trial, adult veterans undergoing CTR or TFR were enrolled January 2012-January 2014, with data analysis February 2020-October 2020. Participants were randomized to receive minocycline 200 mg or placebo 2 h prior to the operation, then minocycline 100 mg or placebo twice daily for 5 days. The Brief Pain Inventory, assessed daily, captured three pain scores: average and worst pain over the past 24 h, and current pain intensity. Fifteen acute pain descriptors based on the pain scores (clusters, mean, median, pain scores on POD 10, and linear slopes) were compared as predictors of time to pain resolution.

RESULTS

Of 131 randomized participants, 114 (83 CTR, 31 TFR) were included. Average pain over the last 24 h reported on POD 10 best predicted time to pain cessation. Every one-point increase in the average pain score was associated with a 36.0% reduced rate of pain cessation (HR, 0.64, 95% CI 0.55-0.74, p < 0.001). Average pain on POD 10 was significantly associated with the development of CPSP at 90 days (OR 1.74, 95% CI 1.30-2.33, p value < 0.001). The optimal cutoff score for the high-risk group was determined as average pain on POD 10 ≥ 3.

CONCLUSIONS

This study validates prior work and demonstrates the importance of assessing pain severity on POD 10 to identify patients at high risk for CPSP who are most likely to benefit from early pain intervention. Future research in diverse surgical cohorts is needed to further validate pain assessment on POD 10 as a significant predictor of CPSP.

Effect of Intraoperative Dexmedetomidine Dose on Postoperative First Night Sleep Quality in Elderly Surgery Patients: A Retrospective Study With Propensity Score-Matched Analysis

Background: Postoperative sleep disorder is common in elderly surgery patients, and it often worsens their recovery after surgery. This study aimed to explore the effect of intraoperative dexmedetomidine dose on postoperative sleep quality.

Methods: Based on information regarding dexmedetomidine use during surgery from an electronic medical record system, 4,349 elderly surgery patients were divided into three groups: 1,374 without intraoperative use of dexmedetomidine (Non-DEX), 917 with dexmedetomidine 0.1–0.2 μg/kg/h (Low-DEX), and 2,058 with dexmedetomidine >0.2 μg/kg/h (High-DEX). The numerical rating scale (NRS) for sleep disturbance during the first night after surgery was recorded, and the incidence of NRS ≥ 6 was considered the primary outcome.

Results: NRS (P < 0.001) and incidence of severe sleep disturbance (P < 0.001) were lower in patients receiving intraoperative dexmedetomidine than in those without the intraoperative use of dexmedetomidine. Patients in the Low-DEX group had the lowest incidence, followed by those in the High-DEX and Non-DEX groups (6.7% vs. 13.7% vs. 19.5%). After propensity score matching, 906 pairs of elderly surgery patients were included in the Low-DEX and High-DEX groups, and the Low-DEX group had lower NRS (2.7 ± 2.1 vs. 3.1 ± 2.4, P < 0.001) than the High-DEX group. The incidence of severe sleep disturbance was lower in the Low-DEX group than in the High-DEX group (6.6% vs. 12.8%) with an odds rate of 0.48 (95% confidence interval, 0.35 to 0.67).

Conclusions: For elderly patients, intraoperative dexmedetomidine use can significantly improve the quality of the first night sleep after surgery. Low-dose (0.1–0.2 μg/kg/h) dexmedetomidine can have an improvement effect on sleep quality, and it is recommended to improve the quality of postoperative sleep.