Comparison of postoperative pain after open and endoscopic carpal tunnel release: A randomized controlled study

Open versus Single- or Dual-Portal Endoscopic Carpal Tunnel Release: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Compared to the traditional open carpal tunnel release (OCTR), the additional safety and efficacy benefits of endoscopic carpal tunnel release (ECTR) remains unclear. The aim of this study is to evaluate the outcomes of ECTR versus conventional OCTR as well as determine if a difference exists between the 2 most common endoscopic techniques: the single-portal and the dual-portal endoscopic technique.

METHODS

We conducted a systematic literature search of Medline, Embase, PubMed, and the CENTRAL. Additional articles were identified by handsearching reference lists. We included all randomized controlled trials that compared outcomes of ECTR with OCTR technique. Outcomes assessed included length of surgery, patient reported symptom and functional measures, time to return to work, and complications. A sub-group analysis was performed to indirectly compare single- versus dual-portal endoscopic approaches. Statistical analysis was performed via a random-effects model using Review Manager 5 Software.

RESULTS

A meta-analysis of 23 studies revealed a significantly higher incidence of transient postoperative nerve injury with ECTR, regardless of the number of portals, as compared with OCTR, although overall complication and re-operation rates were equivalent. Scar tenderness was significantly diminished with dual-portal endoscopic release when compared to single-portal and open methods. The rates of pillar pain, symptom relief, and patient reported satisfaction did not differ significantly between treatment groups.

CONCLUSIONS

Although endoscopic surgery may be appealing in terms of reduced postoperative morbidity and a faster return to work for patients, surgeons should be mindful of the associated learning curve and higher incidence of transient nerve injury. Further study is required to identify if an advantage exists between different endoscopic techniques.

Scalpel versus Electrocautery for Surgical Skin Incision in Open Carpal Tunnel Release

Background: Electrocautery is an option for skin incision for the neck, abdominal or inguinal surgery, but is not generally used for hand surgery. The aim of this study was to clarify whether electrocautery skin incision would be beneficial in open carpal tunnel release (OCTR). Methods: A total of 16 patients with carpal tunnel syndrome underwent skin incision for OCTR using either a scalpel (n = 9) or a microdissection diathermy needle (n = 7). Postoperative pain was assessed using a visual analogue scale (VAS 0-100 mm) daily from postoperative days 1 till 7. Results: The diathermy group reported higher VAS scores (mean 80 mm) on the first postoperative day versus the scalpel group mean of 35 mm (p < 0.001). We continued measuring pain for 7 days after the surgery and found higher VAS scores for the diathermy group in the first 6 days. Conclusions: The use of electrocautery is associated with greater pain score in the first postoperative 6 days following OCTR. Level of Evidence: Level III (Therapeutic).

Common peripheral nerve entrapments in the upper limb

Entrapment of peripheral nerves can occur as they travel through restrictive spaces. This nerve compression can result in a constellation of signs and symptoms, which are often called syndromes. Patients initially report pain, paraesthesia and numbness, followed by weakness and clumsiness and, ultimately, muscle wasting. The specific region of paraesthesia and pain and the specific muscle weakness is determined by the peripheral nerve involved and the location of the entrapment. Diagnosis is mainly based on history and examination. Further investigations are available for atypical presentations. Each syndrome has its own set of risk factors, but repetitive action and muscle overuse are commonly associated with most syndromes. The treatment is activity modification followed by steroid injection and finally surgical decompression for ongoing persistent symptoms or severe initial presentation. This article outlines the history, examination, possible investigations and management for common peripheral nerve entrapments of the median, ulnar and radial nerves.

The Relevance of Collision Tests and Quantitative Sensory Testing in Diagnostics and Postoperative Outcome Prediction in Carpal Tunnel Syndrome

Background

The gold standards for the diagnosis and treatment of carpal tunnel syndrome (CTS) and its outcome are undecided. Using clinical and electrophysiological methods, we tried to establish which fibers achieved full postoperative recovery, and the possibility of using non-standard electrophysiological tests as outcome predictors.

Methods

The study group consisted of 35 patients and controls. The Historical–Objective Scale, standard neurography, conduction velocity distribution tests (CVD), and quantitative sensory testing (QST) were performed before and after CTS surgery.

Results

Clinical improvement was observed on average in 54.3% of the patients, higher in less advanced CTS. All parameters improved significantly after surgery, except for CVD; most remained worse than in the controls. Only QST parameters fully returned to normal limits. Patient age and CTS severity were important in the estimation of the risk of no improvement.

Conclusions

The efficiency of minimally invasive CTS surgery is higher in younger patients with less advanced CTS. Complete recovery was present only in small fibers; larger fibers could most likely be responsible for residual signs. We did not notice any benefits in CTS diagnosis using methods of small fiber assessment. QST seemed to be useful in the diagnosis of residual signs, and in deciding upon possible reoperation.

Assessment of Pain During Nerve Conduction Studies in Patients With Carpal Tunnel Syndrome

Purpose

Patients with suspected carpal tunnel syndrome (CTS) often undergo nerve conduction studies (NCSs). Although patients sometimes complain of NCS-related discomfort, including severe pain, pain evaluations during such NCSs are lacking. We aimed to measure the pain experienced by patients with CTS during NCSs.

Methods

This prospective study included 30 patients with CTS who underwent NCSs between April 2018 and March 2019. Pain because of electrical stimulation during NCSs was evaluated using a visual analog scale, and we statistically analyzed pain-related factors such as age, sex, complications, severity grading scale, the intensity of maximum stimulation, and examination time.

Results

The mean visual analog scale score for NCSs was 5.2, and the visual analog scale score increased as the intensity of maximum stimulation and examination time increased.

Conclusions

We measured the pain because of electrical stimulation experienced by patients with CTS during NCSs. Our findings indicate that medical staff must be mindful of the potential pain experienced by patients during NCSs and educate patients regarding the necessity of the examination and its procedures.

Type of study/level of evidence

Diagnostic Ⅳ.

Comparison of the Therapeutic Effect of the Mini-Open Incision and Conventional Open Neurolysis of the Median Nerve for Carpal Tunnel Syndrome

OBJECTIVE

The aim of this study was to compare the therapeutic effects of the mini-open incision and conventional open surgery for carpal tunnel syndrome (CTS).

METHODS

The clinical data of 52 patients with CTS treated at the First Affiliated Hospital of the University of Science and Technology of China from October 2020 to February 2022 were retrospectively analyzed. The patients were divided into the conventional open surgery group (28 cases) and the mini-open incision group (24 cases) according to different surgical incisions applied. The incision length, operation time, time until postoperative return to work, and complications were observed in the two groups. The Visual Analog Scale (VAS) for pain at one day, one month, and three months after surgery and the Boston Carpal Tunnel Questionnaire scores before, at one month, and at three months after surgery were compared between the two groups.

RESULTS

The incision length, operation time, and time until return to work in the mini-open incision group were all shorter than those in the conventional open surgery group (2.58 ± 0.35 vs. 7.32 ± 0.61 cm, 18.67 ± 2.62 vs. 29.46 ± 3.42 min, and 5.33 ± 1.40 vs. 13.86 ± 2.70 d, respectively), and differences were statistically significant (P < 0.05 in all). The VAS scores in the mini-open incision group were lower than those in the conventional open surgery group at one day and one month after surgery, while the difference in the VAS scores at three months after surgery was not statistically significant between the two groups. There was no statistically significant difference in neurological recovery between the two groups at postoperative follow-ups (P > 0.05). The incidences of postoperative scar hyperplasia and scar pain were higher in the conventional open surgery group than those in the mini-open incision group, and differences were statistically significant (P < 0.05 in both).

CONCLUSION

Mini-open incision surgery for CTS was a safe and reliable procedure with a precise therapeutic effect, minimal surgical trauma, and high postoperative comfort for patients and could achieve enhanced recovery. Trial Registration. This trial is registered with ChiCTR2200064631.

Endoscopic carpal tunnel release with or without suture: Does it make a difference? A case-control study

A case-control study was conducted to compare wound healing with or without skin suture after endoscopic carpal tunnel release. The primary endpoint was esthetics on the Manchester Scar Scale (MSS). Patients were recruited between April 2016 and April 2017. Inclusion criteria comprised carpal tunnel syndrome with clinical and electromyographic confirmation on the Canterbury NCS (nerve conduction studies) Severity Scale. Age, gender, occupation, handedness, smoking status, and operated side were noted. In the first group (64 patients) the skin was not sutured. In the second group (44 patients) the skin was closed Ethilon™ 5-0 intradermal running suture. All 108 patients had 3 months' follow-up. Since data were not normally distributed, analysis was performed with the Mann-Whitney U test (MWU) for independent samples. There were no significant differences in age (p = 0,416), gender (p = 0.670) or occupation (p = 0.725) between groups. MSS score did not significantly differ between groups (MWU test; p = 0.529): sutureless, 6.64 ± 1.21; sutured, 6.45 + 1.09. Thus, sutureless wound closure can be a useful option in treating carpal tunnel syndrome by a single-portal endoscopic technique. That the wound remains open enables easy evacuation of any hematoma, avoiding pain due increased intra-tissular pressure.

Carpal Tunnel Release Surgery- A Systematic Review of Open and Endoscopic Approaches

CONTEXT

Carpal tunnel syndrome (CTS) is the most frequent peripheral compression-induced neuropathy observed in patients worldwide. Surgery is necessary when conservative treatments fail and severe symptoms persist. Traditional Open carpal tunnel release (OCTR) with visualization of carpal tunnel is considered the gold standard for decompression. However, Endoscopic carpal tunnel release (ECTR), a less invasive technique than OCTR is emerging as a standard of care in recent years.

EVIDENCE ACQUISITION

Criteria for this systematic review were derived from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two review authors searched PubMed, MEDLINE, and the Cochrane Database in May 2018 using the following MeSH terms from 1993-2016: 'carpal tunnel syndrome,' 'median nerve neuropathy,' 'endoscopic carpal tunnel release,' 'endoscopic surgery,' 'open carpal tunnel release,' 'open surgery,' and 'carpal tunnel surgery.' Additional sources, including Google Scholar, were added. Also, based on bibliographies and consultation with experts, appropriate publications were identified. The primary outcome measure was pain relief.

RESULTS

For this analysis, 27 studies met inclusion criteria. Results indicate that ECTR produced superior post-operative pain outcomes during short-term follow-up. Of the studies meeting inclusion criteria for this analysis, 17 studies evaluated pain as a primary or secondary outcome, and 15 studies evaluated pain, pillar tenderness, or incision tenderness at short-term follow-up. Most studies employed a VAS for assessment, and the majority reported superior short-term pain outcomes following ECTR at intervals ranging from one hour up to 12 weeks. Several additional studies reported equivalent pain outcomes at short-term follow-up as early as one week. No study reported inferior short-term pain outcomes following ECTR.

CONCLUSIONS

ECTR and OCTR produce satisfactory results in pain relief, symptom resolution, patient satisfaction, time to return to work, and adverse events. There is a growing body of evidence favoring the endoscopic technique for pain relief, functional outcomes, and satisfaction, at least in the early post-operative period, even if this difference disappears over time. Several studies have demonstrated a quicker return to work and activities of daily living with the endoscopic technique.

STUDY OF EFFICIENCY OF SURGICAL TREATMENT OF TUNNEL NEUROPATHY OF THE UPPER EXTREMITY AT ELDERLY PATIENTS

The research objective are the assessment and increase in efficiency of treatment of tunnel neuropathy of the upper extremities at patients aged from 60 years and also more senior.Material and methods - the examination and the subsequent treatment of 115 patients of age category 60 years and more senior with compression pathology of nerves of the upper extremity. Diagnostic process included clinical examination, an ultrasonography, an electroneuromyography (EMG).Results - total number of cases of neuropathy is 140 at 115 patients due to the multiple combined compression of nerves in several channels in 25 cases. All patients included in a research had performed open decompression of a nerve . The excellent result was received at 32 (27.8%) patients, good - in 68 (59.1%) cases, satisfactory - at 13 (11.3%) patients, unsatisfactory - at 2 (1.7%) patients.The conclusion - expeditious treatment of tunnel neuropathy at elderly patients allows to improve quality of life of patients and gives low level of complications.

Carpal Tunnel Syndrome Surgery: What You Should Know

Carpal tunnel release (CTR) surgery continues to evolve. Carpal tunnel syndrome remains a primarily clinical diagnosis, although ultrasound has supplemented electrodiagnostic testing as a confirmatory tool. Magnetic resonance imaging of the carpal tunnel has also showed some promise as an alternative method for the examination of the median nerve. Open CTR surgery remains the traditional, and most popular, method of CTR. Wide-Awake, with Local Anesthesia only, and No Tourniquet CTR has emerged as a means to decrease cost and improve pain control and convenience for patients. Endoscopic CTR is increasing in popularity due to its more rapid recovery. The safety profile of endoscopic CTR has improved, and recent studies show similar rates of major complications between open and endoscopic techniques. Nonsurgeon operated ultrasound-guided techniques for release of the transverse carpal ligament have emerged. While promising in early studies, the current evidence in their favor is limited in terms of patient numbers and direct comparison with other techniques. The outcomes of CTR continue to be excellent. Recent research has demonstrated that nerve conduction continues to recover postoperatively over a longer period of time than previously believed. Patient psychological factors play a significant role in outcomes after surgery but do not appear to limit the improvement provided by intervention.

Arm sling after carpal tunnel surgery: myth or evidence based?

Arm sling elevation is widely used after hand surgery to prevent swelling and pain. This prospective cohort study investigated whether arm sling elevation has any value after carpal tunnel release surgery. Patients were assigned to one of two groups after carpal tunnel release: with or without arm sling elevation. The primary outcome was postoperative swelling. Secondary outcomes were pain and symptom relief and functional outcome. Volumetric analysis showed no significant difference between the sling and non-sling group. Pain scores and improvement of symptom severity and functional status scores were similar for both groups. Thirty-eight per cent found the sling uncomfortable. These results do not support routine use of arm sling elevation after carpal tunnel release. Level of evidence: III.

Carpal Tunnel Release Surgery Plus Intraoperative Corticosteroid Injection versus Carpal Tunnel Release Surgery Alone: A Double Blinded Clinical Trial

Background: Carpal tunnel syndrome is a prevalent disease with significant morbidity. The current treatments range from oral medication and local corticosteroid injection to surgical carpal tunnel release (CTR). In this study, we tried to assess the results of Carpal Tunnel Release surgery in combination with the anti-inflammatory effect of local corticosteroid injection. Methods: 65 patients were enrolled by clinical and electrodiagnostic tests and randomly divided into two groups, 32 in group one which underwent surgery with Dexamethasone injection and 33 in group 2 which intervened with carpal tunnel release surgery alone. Data on Boston questionnaire of patients were conducted before and two weeks after surgery. Distal motor and sensory latencies of patients were recorded before and two months after surgery. Mean values were compared between groups before and after surgery. Results: The mean preoperative Boston index was 35.83 in group one and 37.7 in group two, these data postoperative were 15.83 and 19.15 respectively. The mean preoperative distal sensory latency was 54.8 in group one and 47.6 in group two, these data postoperative were 34.1 and 35.1 respectively. The mean preoperative distal motor latency was 63.2 in group one and 62.3 in group two, these data postoperative were 44.5 and 46.55 respectively. Conclusions: CTR surgery plus local corticosteroid injection did not significantly change in results of Electrodiagnostic test or Boston index compared to the non-injection group.

Sonographic follow-up after endoscopic carpal tunnel release for severe carpal tunnel syndrome: a one-year neuroanatomical prospective observational study

BACKGROUND

Endoscopic carpal tunnel release (ECTR) has been gradually adopted for the treatment of severe carpal tunnel syndrome (CTS). However, perioperative assessment of neuroanatomical parameters of median nerve, which are important determinant of median nerve recovery, has rarely been reported. This one-year prospective study aimed to investigate the natural history of the neuroanatomical morphology of the median nerve after ECTR in severe CTS patients by high-frequency ultrasonography and assess the ability of neuroanatomical measures to quantify morphological recovery of the median nerve after ECTR.

METHODS

This study recruited 31 patients (44 wrists) with a definitive diagnosis of severe CTS and underwent ECTR operation. The edema length (EL) of median nerve from the inlet of the carpal tunnel to the proximal wrist was detected on long axis imaging plane and the anteroposterior diameter (D) and cross-sectional area (CSA) at the inlet of the carpal tunnel on short axis imaging plane were detected by high frequency ultrasound. All these metrics were detected at 3 days before surgery and at the 2nd week, 4th week, 3rd month, 6th month and 12th month after surgery separately.

RESULTS

There was no significant difference of each parameter between the 2-week postoperative (1.914 ± 0.598 cm in EL, 0.258 ± 0.039 cm in D and 0.138 ± 0.015 cm2 in CSA) and 3-days preoperative time points (P-EL =0.250; P-D = 0.125; P-CSA =0.712). From the fourth week to the third month after surgery, the parameters quickly improved. The EL (0.715 ± 0.209 cm), D (0.225 ± 0.017 cm) and CSA (0.117 ± 0.012 cm2) at the 3- month postoperative time points were more reduced than at the fourth week after surgery (P-EL < 0.001; P-D = 0.038; P-CSA =0.014). Thereafter, the neurological anatomy parameters recovered slowly. By the 12-month postoperative time points, the three parameters were neuroanatomically close to normal. Compared to the control group in D (0.213 ± 0.005 cm), there was no difference at the 12-month time point (0.214 ± 0.009 cm, P = 0.939). However, the difference in EL (0.098 ± 0.030 cm vs. 0.016 ± 0.011 cm) and CSA (0.103 ± 0.008 cm2 vs. 0.073 ± 0.005 cm2) between patients and healthy volunteers at the 12-month time point still existed (P-EL < 0.001; P-CSA < 0.001).

CONCLUSIONS

Neuroanatomical parameters were gradually improved after ECTR surgery. The best time for US follow up is at 3-month postoperative time point for patients who do not show clinical improvement, since at this time the change is the greatest for most CTS patients. This study has been registered in Chinese Clinical Trial Registry: ChiCTR-ROC-17014068 (retrospectively registered 20-12-2017).