Long-term analysis of patients having surgical treatment for carpal tunnel syndrome

doi:10.1016/S0363-5023(86)80104-6

The Journal of Hand Surgery

Volume 11, Issue 1, January 1986, Pages 59-66

https://doi.org/10.1016/S0363-5023(86)80104-6 Get rights and content

This retrospective study of 100 patients who had surgical treatment for their carpal tunnel syndrome was performed to determine what factors.were associated with long-term success or failure. One hundred thirty hands were treated surgically with an average follow-up of 4 years (range, 2 to 6 years). All patients were given a course of conservative treatment that included steroid injection(s) and splinting until the patients were refractory to such therapy. Over 250 injections were given (117 wrists), with the average benefit time of 27 weeks (range 0 to 330). Most patients received two to three injections (maximum of nine). Variables associated with a failure to have long-term benefit after operation included weakness or atrophy of the abductor pollicis brevis muscle, presence of a predisposing condition, and failure to benefit from the initial steroid injection. Conversely, all 51 hands that had relief from median nerve paresthesia for more than 6 months by conservative therapy alone received long-term relief after surgery. Steroids were least effective in hands that had muscle involvement. Fifteen of the 40 hands with muscle involvement regained their muscle mass by the time of the final examination.

References (34)

MR Wood
Hydrocortisone injections for carpal tunnel syndrome
Hand
(1980)
DP Green
Diagnostic and therapeutic value of carpal tunnel injection
J Hand Surg
(1984)
MH McGrath
Local steroid therapy in the hand
J Hand Surg
(1984)
RI MacDonald et al.
Complications of surgical release for carpal tunnel syndrome
J Hand Surg
(1978)
DM Lichtman et al.
Carpal tunnel release under local anesthesia: evaluation of the outpatient procedure
J Hand Surg
(1979)
RH Gelberman et al.
Carpal tunnel syndrome. Results of a prospective trial of steroid injection and splinting
J Bone Joint Surg [Am]
(1980)
JA Schuchmann et al.
Evaluation of local steroid injection for carpal tunnel syndome
Arch Phys Med Rehabil
(1971)
JL Roffe et al.
Le syndrome du canal carpien
Nouv Presse Med
(1981)
AP Melmed
Spontaneous bilateral rupture of the calcaneal tendon during steroid therapy
J Bone Joint Surg
(1965)
MA Cowan et al.
Simultaneous bilateral rupture of the Achilles tendon due to triamcinolone
Br Med J
(1961)

AM Ismail et al.

Rupture of the patellar ligament after steroid infiltration. Report of a case

J Bone Joint Surg [Br]

(1969)

R Sweetman

Corticoid steroid arthropathy and tendon rupture

J Bone Joint Surg [Br]

(1969)

HB Lee

Avulsion and rupture of the tendon-calcaneus after injection of hydrocortisone

Br Med J

(1957)

RA Frieberg et al.

The scallop sign and spontaneous rupture of finger extensor tendons in rheumatoid arthritis

Clin Orthop

(1972)

RH Fitzgerald

Intrasynovial injection of steroids: uses and abuses

Mayo Clinic Proc

(1976)

JT Cassidy et al.

Cutaneous atrophy secondary to intra-articular corticosteroid administration

Ann Intem Med

(1966)

O Steinbrocker et al.

Cited by (196)

A Systematic Review of the Outcomes of Carpal Ligament Release in Severe Carpal Tunnel Syndrome
2023, Journal of Hand Surgery
Citation Excerpt :
This study highlighted that despite the wealth of literature on the subject, based on the available evidence, we cannot precisely identify the patient population that would benefit most from CTR in the setting of severe disease. There may be some subsets of patients with severe disease, such as the elderly, those with loss of protective sensation, or with thenar atrophy, who would not experience substantial improvement after surgery.72,73,82,93–96 However, studies reporting PROMs demonstrated improvement after surgery among these subgroups.21,29,41,44,58
Indications for surgical treatment of severe carpal tunnel syndrome (CTS) are controversial. The aim of this study was to review the outcomes reported in the literature of carpal tunnel release in patients with severe CTS.
A systematic review of the outcomes of carpal tunnel release in patients with severe CTS was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcome measures included change in symptoms, sensation (2-point discrimination, light touch), thenar atrophy, strength (power and pinch grip), electrophysiology, median nerve morphology, and patient-reported outcome measures. Outcomes are reported by ranges of the percentage of patients/hands improved in the included studies.
Thirty-eight papers were selected, representing 2,531 patients and 2,712 hands. Demographic information on age and sex were available for a total of 1,542 patients. Mean age ranged from 49.8 to 83 years and 72% were female. All studies that assessed patient-reported outcome measures before and after surgery reported significant improvements. Complete resolution of paresthesia occurred in 55%–98% of hands across different studies. Resolution of numbness occurred in between 39% and 94% of hands. Pain completely resolved in 64%–100% and weakness in 60%–75% of hands. Two-point discrimination and light touch improved postoperatively. Power grip, key, tripod, index-thumb pulp pinch, and thumb opposition increased. Motor and sensory amplitudes, distal motor latencies, and sensory conduction velocities improved. Patient-reported outcomes indicated symptomatic improvement and reduced disability.
Symptomatic improvement following carpal tunnel release in patients with severe CTS can occur. Patients should be counseled about the unpredictability of the outcomes and factors that might affect outcomes.
Therapeutic IV.
The Utility of the Carpal Tunnel Syndrome-6 for Predicting the Outcomes of Carpal Tunnel Release
2022, Journal of Hand Surgery
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.
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.
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.
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.
Prognostic II.
Self-Reliance and Postoperative Hand Recovery After Simultaneous, Bilateral Endoscopic Carpal Tunnel Release: A Prospective Study
2022, Journal of Hand Surgery
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.
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.
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.
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.
Therapeutic II.
The Epidemiology of Carpal Tunnel Revision Over a 1-Year Follow-Up Period
2021, Journal of Hand Surgery
Citation Excerpt :
Finally, our database follow-up data are limited beyond 1-year of follow-up and limited by the time of implementation of ICD-10. However, we believe that revision surgeries within this timeframe best represent those patients with persistent symptoms, consistent with findings from prior studies.5–7 In conclusion, our study identified a rate of revision carpal tunnel surgery of 4.8% within the first postoperative year.
To establish the incidence of revision carpal tunnel surgery within a 1-year postoperative period using a national administrative database. This information has been unknown until this point because of the absence of laterality-specific coding with the International Classification of Diseases, Ninth Edition and earlier coding systems.
Data were collected from the Humana insurance database using PearlDiver patient records from 2015 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes related to carpal tunnel diagnosis and release. Codes were used to identify patients who underwent carpal tunnel release (CTR) and had revision CTR within a 1-year follow-up period. Patient demographic characteristics, including age, sex, medical comorbidities, and smoking status, were collected. In addition, multivariable analysis of the risk of a revision procedure within 1 postoperative year was performed to determine independent risk factors, including the surgical approach, associated with revision CTR.
Among 4,549 patients who underwent a primary CTR during the study period, 207 patients (4.8%) underwent a revision CTR within 1 year. The average time from the primary CTR to the revision CTR was 135 days (standard deviation, 99.1 days; range, 21–365 days). Primary endoscopic CTR was associated with an increased rate of revision CTR (odds ratio, 1.3; 95% confidence interval, 1.2–1.6). Patient factors associated with a higher likelihood of requiring revision CTR included diabetes mellitus, tobacco use, psychiatric condition, cervical disease, and history of cubital tunnel release.
This study identified a rate of revision CTR of 4.8% within the first postoperative year. Both the surgical technique and patient-specific risk factors influence the likelihood of requiring revision surgery. Notably, an endoscopic approach is associated with a higher risk of revision surgery.
Prognostic II.
Recurrent and persistent carpal tunnel syndrome: “Triple-therapy approach”
2020, Journal of Orthopaedics
Various procedures have been described for patients undergoing a revision carpal tunnel release. These can include repeat open decompression with external or internal neurolysis, tenosynovectomy, endoscopic release, various flap techniques, saphenous vein wrapping and use of prosthetic implants. This study reports a case series of 30 consecutive patients who underwent revision carpal tunnel release at single institution from 2012 to 2018. Our surgical plan in all the patients involved a combination of these three techniques (triple therapy approach): neurolysis (external or internal) and tenosynovectomy, collagen matrix conduit wrap (NeuraWrap; Integra LifeSciences or Axoguard Nerve Protector, AxoGen Inc), and hypothenar fat flap.
A total of 30 patient records were identified. The index surgery was performed by a variety of surgeons at varied private institutions as well as the VA hospital. However, all of the revision interventions in this series were performed by the senior author (Z.J.P.). Demographic data (age, sex, hand dominance, comorbidities, alcohol, and smoking history) were collected. Preoperative and postoperative symptoms were recorded for all patients, including: subjective outcomes, need for additional surgery and complications. Mean VAS preoperatively and postoperatively were compared using a paired t-test. All statistical analyses were performed with SPSS 20 (IBM, Chicago, IL).
Patient reported measures of resolution of symptoms and VAS scores documented at 3 months. Of the 30 patients who underwent surgery for persistent or recurrent carpal tunnel syndrome, symptoms resolved completely in 25 patients. 2 patients were lost to follow up. 3 patients showed no improvement. The mean preoperative VAS score was 4.37 and declined to 1.23 after surgery (P < .0001).
Our study demonstrates that a combination of neurolysis and tenosynovectomy along with a nerve wrap and hypothenar fat flap should be considered in patients presenting with recurrent or persistent carpal tunnel syndrome.
A case series of seven patients with recurrent median nerve neuropathy treated by the revision surgery of median nerve neurolysis and wrapping with radial artery perforator adipose flap
2020, Journal of Plastic, Reconstructive and Aesthetic Surgery
Adhesion neuropathy of the median nerve with persistent pain can be a challenging problem. Currently, coverage of the median nerve with a well-vascularized soft tissue is deemed necessary after secondary neurolysis. Herein, we reviewed the outcomes of seven patients with a persistent median nerve neuropathy after a primary open carpal tunnel release or a median nerve repair, treated with neurolysis and median nerve wrapping with radial artery perforator adipose flaps. During the revision surgery, after a careful and complete neurolysis of the scarred median nerve, the distally based radial artery perforator adipose flap without its fascia was raised and rotated to wrap the median nerve. The mean size of the perforator flap was 1146 mm², which was enough to wrap the median nerve in all patients. At 26 months postsurgery, both the visual analog scale score for pain with tingling, and the patient-reported outcome measures improved. There was no recurrence of the median nerve adhesion neuropathy and no major complications were noted. Tinel's sign at the palmar wrist completely disappeared in four patients and was relieved in three patients. The median distal motor latency becomes recordable, and closer to a normal compound motor action potential postoperatively in all patients. Secondary neurolysis and median nerve wrapping with a radial artery perforator adipose flap, which was modified to be softer and thinner than the radial artery perforator adipofascial flap, was a successful treatment for the recurrent median nerve neuropathy in terms of both pain relief and restoration of the hand function.

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Long-term analysis of patients having surgical treatment for carpal tunnel syndrome

Hand

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Carpal tunnel syndrome. Results of a prospective trial of steroid injection and splinting

J Bone Joint Surg [Am]

Evaluation of local steroid injection for carpal tunnel syndome

Arch Phys Med Rehabil

Le syndrome du canal carpien

Nouv Presse Med

Spontaneous bilateral rupture of the calcaneal tendon during steroid therapy

J Bone Joint Surg

Simultaneous bilateral rupture of the Achilles tendon due to triamcinolone

Br Med J

Rupture of the patellar ligament after steroid infiltration. Report of a case

J Bone Joint Surg [Br]

Corticoid steroid arthropathy and tendon rupture

J Bone Joint Surg [Br]

Avulsion and rupture of the tendon-calcaneus after injection of hydrocortisone

Br Med J

The scallop sign and spontaneous rupture of finger extensor tendons in rheumatoid arthritis

Clin Orthop

Intrasynovial injection of steroids: uses and abuses

Mayo Clinic Proc

Cutaneous atrophy secondary to intra-articular corticosteroid administration

Ann Intem Med