The double tunnels technique: an alternative minimally invasive approach for carpal tunnel syndrome

Carpal tunnel syndrome: updated evidence and new questions

Carpal tunnel syndrome is the most common entrapment neuropathy, affecting quality of life for many people. Although it is a well recognised condition, new insights into epidemiology, diagnosis, and treatment have emerged in the past 6 years. The availability of disease-modifying treatments for rare systemic disorders associated with carpal tunnel syndrome (eg, amyloidosis) should alert clinicians to these diagnostic possibilities. Besides clinical evaluation and electrophysiology, the role of ultrasonography as a diagnostic tool has been confirmed and new ultrasound techniques have been applied, the clinical use and feasibility of which require further investigation. Surgical and non-surgical interventions are beneficial for the treatment of carpal tunnel syndrome and several treatment options are now available, giving clinicians the possibility to choose the best approach for every patient. New diagnostic and therapeutic techniques require further validation.

Diagnostic criteria and outcome measures in randomized clinical trials on carpal tunnel syndrome: a systematic review

BACKGROUND

The diagnostic criteria for carpal tunnel syndrome (CTS) lack uniformity. Moreover, because CTS is a syndrome, there is no consensus as to which signs, symptoms, clinical and complementary tests are more reproducible and accurate for use in clinical research. This heterogeneity is reflected in clinical practice. Thus, establishing effective and comparable care protocols is difficult.

OBJECTIVE

To identify the diagnostic criteria and outcome measures used in randomized clinical trials (RCTs) on CTS.

DESING AND SETTING

Systematic review of randomized clinical trials carried out at the Federal University of São Paulo, São Paulo, Brazil.

METHODS

We searched the Cochrane Library, PubMed, and Embase databases for RCTs with surgical intervention for CTS published between 2006 and 2019. Two investigators independently extracted relevant data on diagnosis and outcomes used in these studies.

RESULTS

We identified 582 studies and 35 were systematically reviewed. The symptoms, paresthesia in the median nerve territory, nocturnal paresthesia, and special tests were the most widely used clinical diagnostic criteria. The most frequently assessed outcomes were symptoms of paresthesia in the median nerve territory and nocturnal paresthesia.

CONCLUSION

The diagnostic criteria and outcome measures used in RCTs about CTS are heterogeneous, rendering comparison of studies difficult. Most studies use unstructured clinical criteria associated with ENMG for diagnosis. The Boston Questionnaire is the most frequently used main instrument to measure outcomes.

REGISTRATION

PROSPERO (CRD42020150965- https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=150965).

Prospective Comparative Analysis Study of Minimally Invasive Surgical Decompressions versus Traditional Surgical Decompression of Carpal Tunnel Syndrome

Objective: Carpal tunnel syndrome (CTS) occurs when there is compression on the median nerve within the carpal tunnel in the wrist joint. It commonly affects those who make frequent, repetitive hand movements, with women being more affected than men. The present study was aimed at comparing minimally invasive and classical surgical decompression techniques for carpal tunnel syndrome. Materials and Methods: One hundred and four patients with CTS who were scheduled for carpal tunnel decompression were chosen at random. The patients were divided into two groups. Group A had standard classical long incision decompression, whereas Group B had minimally invasive decompression. The patients were evaluated with the Boston Functional Score Scale. Between the two groups, a comparison of visit reports was made at 3, 6, and 12 months after surgery. Results: There was no significant difference in patient age (Group A was 38 years old and Group B was 36 years old) and availability of bilateral CTS status (A was 34 and B was 31). The female-male ratios in groups A and B were 3.6 to 0.2 and 3.1 to 0.3, respectively, with a p-value of p<0.05 indicating significant difference. Comparing both groups, the minimally invasive decompression technique showed a high rate of functional hand grip and a low rate of complications including early wound healing, rapid resumption of palmar strength grip, and rapid return to daily activities. Conclusion: The findings indicate that patients who underwent the minimally invasive surgical decompression one-stitch technique showed significant improvement over the traditional method.

Outcome Metrics in the Treatment of Carpal Tunnel Syndrome: A Systematic Review

BACKGROUND

The purpose of this systematic review was to determine the metrics used to assess outcomes after treatment for carpal tunnel syndrome.

METHODS

We performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines of level I and II randomized controlled trials of treatment for carpal tunnel syndrome. We searched the PubMed/MEDLINE electronic database for studies on treatment of carpal tunnel syndrome from January 2008 to January 2018. A total of 105 studies were included in the final analysis. The metrics used to assess outcomes in each studies were collected, compared, and described.

RESULTS

Nearly all the studies used a patient-reported outcome measure (PROM) to assess outcomes (94%). The most common PROMs used were the Boston Carpal Tunnel Questionnaire (60%) and the Visual Analog Scale for pain (51%). Electrophysiological testing and physical examination were also commonly used to assess outcomes (50% and 46%, respectively). Cost, sleep, and return to activities of daily living were assessed in a minority of studies (1%, 1%, and 5%, respectively).

CONCLUSIONS

Successful treatment of carpal tunnel syndrome is commonly defined based on a PROM, highlighting recent efforts to measure outcomes from the patient's perspective. Other patient-centered metrics such as return to work and sleep quality, however, were rarely reported, whereas objective measures such as nerve conduction studies were prevalent. Further work is needed to determine patients' preferred method of measuring outcomes after treatment for carpal tunnel syndrome to inform goal-directed decision-making and treatment.

Minimally Invasive Open Surgical Approach and Outcomes for Carpal Tunnel Syndrome

Objectives:

The most common peripheral neuropathy is carpal tunnel syndrome. The present study aims to describe our minimally invasive open surgical approach for carpal tunnel syndrome and evaluate surgical outcomes.

Methods:

We included 217 patients who were operated in our clinic for carpal tunnel syndrome by minimally invasive open surgical approach. Visual Analogue Scale and Functional Outcome Scale scores were obtained preoperative, postoperative at one month and three months to determine surgical outcomes.

Results:

The mean age of the patients was 55.4±12.8 years (32 to 69), 175 (80.6%) were women and 42 (19.4%) were men. The assessment of carpal tunnel syndrome’s etiology showed that 189 (%87.1%) of the cases were idiopathic, 19 (8.8%) had hypothyroidism, 5 (2.3%) had rheumatoid arthritis and 4 (1.8%) were due to pregnancy. The average improvement of VAS between preoperatively and late postoperatively was 5.41±1.05. The average improvement FOS was 17.44±3.06. They were statistically significant.

Conclusion:

The minimally invasive open surgical approach for carpal tunnel syndrome (an average of 1 cm skin incision) is performed with local anesthesia and successful surgical outcomes are achieved.

APPLICABILITY OF RANDOMIZED TRIALS IN HAND SURGERY: SURVEY STUDY

OBJECTIVE

To assess the applicability of randomized clinical trials and whether certain factors (surgeon experience/journal impact factor) influence their applicability.

METHODS

In this survey study we used the Pubmed/Medline database to select 32 consecutive randomized clinical trials published between 2013 and 2015, involving hand surgery (high/low impact). These studies were independently assessed by 20 hand surgeons (with more or less than 10 years of practice) who answered 4 questions regarding their applicability. Agreement was assessed using Cohen's kappa and comparison of proportions via chi-square statistics. P-value <5% constituted statistical significance.

RESULTS

A total of 640 evaluations were produced, generating 2560 responses. A weak correlation was observed between less and more experienced respondents (kappa <0.2; range 0.119-0.179). Applicability between the least and most experienced respondents was similar (p = 0.424 and p = 0.70). Stratification by journal impact factor showed no greater propensity of applicability (p = 0.29) for any of the groups.

CONCLUSIONS

Low agreement was found between the respondents for the applicability of the randomized studies. Surgeon experience and journal impact do not seem to influence this decision. Level of Evidence II, Prospective comparative study.

Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome-A Systematic Review

OBJECTIVE

To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results. Four systematic reviews and 33 RCTs were included. Surgery versus nonsurgical interventions, timing of surgery, and various surgical techniques and postoperative interventions were studied. Corticosteroid injection was more effective than surgery (strong evidence, short-term). Surgery was more effective than splinting or anti-inflammatory drugs plus hand therapy (moderate evidence, midterm and long-term). Manual therapy was more effective than surgical treatment (moderate evidence, short-term and midterm). Within surgery, corticosteroid irrigation of the median nerve before skin closure as additive to CTS release or the direct vision plus tunneling technique was more effective than standard open CTS release (moderate evidence, short-term). Furthermore, short was more effective than long bulky dressings, and a sensory retraining program was more effective than no program after surgery (moderate evidence, short-term). For all other interventions only conflicting, limited, or no evidence was found.

CONCLUSIONS

Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short-term, midterm, and/or long-term to treat CTS. However there is strong evidence that a local corticosteroid injection is more effective than surgery in the short-term, and moderate evidence that manual therapy is more effective than surgery in the short-term and midterm. There is no unequivocal evidence that suggests one surgical treatment is more effective than the other. Postsurgical, a short- (2-3 days) favored a long-duration (9-14 days) bulky dressing and a sensory retraining program seems to be more effective than no program in short-term. More research regarding the optimal timing of surgery for CTS is needed.