Carpal Tunnel Syndrome: When Excellent Is Not Good Enough

Abstract

Compression of the median nerve at the carpal tunnel is the most prevalent compression syndrome, with an estimated incidence from 0.1% to as high as 10% in the United States. The total estimated cost of carpal tunnel syndrome (CTS), including direct medical costs from surgical treatment, ergonomic aids, and medications is estimated to be over 1 billion dollars annually. There is a plethora of literature pertaining to the diagnosis, treatment, and outcomes of CTS. We have learned that the diagnosis and treatment is extremely effective in patients with primary CTS. So how do we achieve even better results in the diagnosis or operation of a condition that already has >90% success rates? The study “Early versus Delayed Endoscopic Surgery for Carpal Tunnel Syndrome: A Prospective Study” by Chandra et al. looks to address the remaining 10% of disappointing surgical outcomes by investigating an unanswered question—the role of early surgical treatment in CTS. Traditionally, CTS has been thought to be a clinical diagnosis, with electrodiagnostic studies serving as supportive evidence. Still the diagnosis is not perfect, with misdiagnosis being the most common cause of treatment failure. More recently, highresolution imaging with magnetic resonance imaging or ultrasound has been added to the equation by some groups wishing to obtain even more helpful information preoperatively related to the local anatomy and pathology. Many would suggest that history alone is sufficient to make the diagnosis of CTS; this is supported by studies by Ragi (12), who found a typical history in 90% of patients with confirmed CTS, and by Szabo et al. (14), who reported a 96% sensitivity for patients complaining of night pain. However, when examining the same symptom complex in patients without CTS, the specificity of history alone is quite low,