Carpal Tunnel Release Surgery Research Articles

Carpal tunnel syndrome and work.

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome, and it frequently presents in working-aged adults. Its mild form causes 'nuisance' symptoms including dysaesthesia and nocturnal waking. At its most severe, CTS can significantly impair motor function and weaken pinch grip. This review discusses the anatomy of the carpal tunnel and the clinical presentation of the syndrome as well as the classification and diagnosis of the condition. CTS has a profile of well-established risk factors including individual factors and predisposing co-morbidities, which are briefly discussed. There is a growing body of evidence for an association between CTS and various occupational factors, which is also explored. Management of CTS, conservative and surgical, is described. Finally, the issue of safe return to work post carpal tunnel release surgery and the lack of evidence-based guidelines are discussed.

Carpal Tunnel Release Outcomes in Diabetic Versus Non-Diabetic Patients

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy. Diabetes mellitus is the most common disease that predisposes the patients to CTS. Diabetic neuropathy is a progressive disease and diabetics nerve is more susceptible to compression at known sites of anatomic constrains such as in the carpal tunnel; clinical results of carpal tunnel release has been questioned not to be as good as non-diabetic patients. Objectives: This study was carried out to compare the clinical and electrodiagnostic outcomes of diabetic and non-diabetic carpal tunnel release (CTR) surgery. Patients and Methods: Twenty diabetic hands (14 patients) and 18 non-diabetic hands (14 patients) that underwent CTR between Octobers 2009 2012 were evaluated. They were operated by one hand surgeon and were evaluated at least six months after the operation. Clinical symptoms as numbness, pain, paresthesia and nocturnal symptoms were evaluated. Electrodiagnostic results were evaluated preand post-operatively. Results: After surgical release, both groups showed significant improvements in clinical results, as 81.6% of patients had excellent and good outcomes, 18.4% had fair outcomes, and no one had poor outcome. Except for median sensory nerve conduction velocity (NCV) changes that had significant differences between diabetic and non-diabetic groups, other parameters had no significant differences between both groups. Furthermore, significant reverse correlation was found between the duration of CTS and the outcome. Conclusions: Clinical and electrodiagnostic results after CTR are approximately the same in patients with diabetes and without it. Diabetics with CTS as well as non-diabetic patients have satisfactory results after CTR surgery. Furthermore, the duration of CTS has a significant influence on the result of CTR; the shorter duration of diabetes, the better the result of CTR surgery.

Choosing the most efficacious scoring method for carpal tunnel syndrome.

The aim of this study was to determine the most efficacious hand-specific questionnaire to determine functionality in patients with carpal tunnel syndrome. The study included 89 patients who underwent open carpal tunnel release surgery within three years prior to the study. A visual analog scale was used to assess the intensity of pain and paresthesia symptoms. Each participant completed the Boston Carpal Tunnel Questionnaire (BCTQ), the Michigan Hand Outcome Questionnaire (MHQ), the quick form of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and the Duruoz Hand Index (DHI). The BCTQ, pain and paresthesia results were assumed as gold standards. Correlations between the MHQ, QuickDASH, and the DHI were analyzed. A correlation analysis between the variables was tested using Spearman's rho test or Pearson's test for variables. The QuickDASH was well correlated with pain, paresthesia and the BCTQ (p<0.001). The questionnaires complied with each other. In addition to its complicated scoring, the MHQ contained detailed subparameters with similar questions and takes a long time to complete. Further studies may confirm the effective usage of the DHI. The easier QuickDASH questionnaire appears to be more practical for carpal tunnel release patients.

The COL5A1 gene is associated with increased risk of carpal tunnel syndrome.

The direct causes of idiopathic carpal tunnel syndrome (CTS), a common upper limb entrapment neuropathy, remain unknown. It is however generally accepted that an increase in pressure within the carpal tunnel structure, which contains nine flexor tendons, causes compression of the median nerve. The involvement of these tendons in the aetiology of CTS cannot be excluded. Variants within the collagen, type V, alpha 1 (COL5A1) gene, which encodes for the α1 chain of type V collagen, an important regulator of fibril assembly in tendons, have previously been associated with Achilles tendinopathy. The aim of this study was to determine whether these COL5A1 variants are also associated with CTS. One hundred and three self-reported coloured participants, with a history of carpal tunnel release surgery (CTS) and 150 matched control (CON) participants without any reported history of CTS symptoms were genotyped for the COL5A1 rs13946 (C/T), rs14774622 (C/T)/rs55748801 (G/A) (W/M where W = CG), rs12722 (C/T) and rs71746744 (-/AGGG) variants. The TT genotype of COL5A1 rs13946 was significantly over-represented (p = 0.007) in the CON (69.3 %) compared to that in the CTS (50.6 %) group. When the combined rs14774622/rs55748801 and rs12722 genotypes were analysed, the WW + CC (41.7 %, p = 0.008) and WW + CT (40.3 %, p = 0.009) genotypes were significantly over- and under-represented in the CON group, respectively, when compared to the CTS group (24.5 % WW + CC, 59.2 % WW + CT). Furthermore, the T-W-C (51.2 %, p < 0.001) and C-W-C (15.9 %, p = 0.005) inferred haplotypes were significantly over- and under-represented in the CON compared to the CTS (34.9 % T-W-C, 26.8 % C-W-C). In conclusion, this is the first study to report that variants within the functional COL5A1 3'-untranslated region are associated with the CTS. Further studies are required to replicate these findings.

Differentiation between nerve and adipose tissue using wide-band (350-1,830 nm) in vivo diffuse reflectance spectroscopy.

Intraoperative nerve localization is of great importance in surgery. In certain procedures, where nerves show visual resemblance to surrounding adipose tissue, this can be particularly challenging for the human eye. An example of such a delicate procedure is thyroid and parathyroid surgery, where iatrogenic injury of the recurrent laryngeal nerve can result in transient or permanent vocal problems (0.5-2.0% reported incidence). A camera system, enabling nerve-specific image enhancement, would be useful in preventing such complications. This might be realized with hyperspectral camera technology using silicon (Si) or indium gallium arsenide (InGaAs) sensor chips. As a first step towards such a camera, we evaluated the performance of diffuse reflectance spectroscopy by analysing spectra collected during 18 thyroid and parathyroid resections. We assessed the contrast information present in two different spectral ranges, for respectively Si and InGaAs sensors. Two hundred fifty three in vivo, wide-band diffuse reflectance spectra (350-1,830 nm range, 1 nm resolution) were acquired on 52 tissue spots, including nerve (n = 22), muscle (n = 12), and adipose tissue (n = 18). We extracted 36 features from these spectroscopic data: 18 gradients and 18 amplitude differences at predefined points in the tissue spectra. Best distinctive feature combinations were established using binary logistic regression. Classification performance was evaluated in a cross-validation (CV) approach by leave-one-out (LOO). To generalize nerve recognition applicability, we performed a train-test (TT) validation using the thyroid and parathyroid surgery data for training purposes and carpal tunnel release surgery data (10 nerve spots and 5 adipose spots) for classification purposes. For combinations of two distinctive spectral features, LOO revealed an accuracy of respectively 78% for Si-sensors and 95% for InGaAs-sensors. TT revealed accuracies of respectively 67% and 100%. Using diffuse reflectance spectroscopy we have identified that InGaAs sensors are better suited for automated discrimination between nerves and surrounding adipose tissue than Si sensors.

Effectiveness of mechanical traction as a non-surgical treatment for carpal tunnel syndrome compared to care as usual: study protocol for a randomized controlled trial

BackgroundCarpal tunnel syndrome (CTS) is a common condition (prevalence of 4%) where the median nerve is compressed within the carpal tunnel resulting in numbness, tingling, and pain in the hand. Current non-surgical treatment options (oral medication, corticosteroid injections, splinting, exercise, and mobilization) show limited effects, especially in the long-term. Carpal tunnel release (CTR) surgery is effective in 70 to 75% of patients, but is relatively invasive and can be accompanied by complications. In an observational study, mechanical traction proved to be effective in up to 70% of patients directly after treatment and in 60% after two years follow-up. This randomized controlled trial (RCT) will examine the effectiveness of mechanical traction compared to care as usual in CTS.Methods/DesignPatients diagnosed with CTS will be recruited from an outpatient neurology clinic and randomly assigned to the intervention group (mechanical traction) or the control group (care as usual). Participants in the intervention group will receive 12 treatments with mechanical traction during six consecutive weeks. Primary outcome is symptom severity and functional status, which are measured with the Boston Carpel Tunnel Questionnaire (BCTQ). Secondary outcomes are quality of life (WHOQOL-BREF), health related resource utilization, and absenteeism from work. Outcomes will be assessed at baseline, and at 3, 6, and 12 months after inclusion. Linear mixed effect models will be used to determine the change from baseline at 12 months on the BCTQ, WHOQOL-BREF, absenteeism from work and health related resource utilization. The baseline measurement, change from baseline at three and six months, as well as duration of symptoms until inclusion, age, gender, and co-morbidity will be included as covariates The Pearson’s correlation coefficient will be generated to assess the correlation between depression and anxiety and treatment outcome.DiscussionSince current non-surgical treatment options are not effective long-term and CTR is relatively invasive, there is a need for an effective and non-invasive treatment option. Mechanical traction is a safe treatment option that may provide a good alternative for the usual care. Considering the prevalence of CTS, the study is of great clinical value to a large patient population.Trial registrationClinical Trials NL44692.008.13 (registered on 19 September 2013).

Temporal trend of carpal tunnel release surgery: a population-based time series analysis.

BackgroundCarpal tunnel release (CTR) is among the most common hand surgeries, although little is known about its pattern. In this study, we aimed to investigate temporal trends, age and gender variation and current practice patterns in CTR surgeries.MethodsWe conducted a population-based time series analysis among over 13 million residents of Ontario, who underwent operative management for carpal tunnel syndrome (CTS) from April 1, 1992 to March 31, 2010 using administrative claims data.ResultsThe primary analysis revealed a fairly stable procedure rate of approximately 10 patients per 10,000 population per year receiving CTRs without any significant, consistent temporal trend (p = 0.94). Secondary analyses revealed different trends in procedure rates according to age. The annual procedure rate among those age >75 years increased from 22 per 10,000 population at the beginning of the study period to over 26 patients per 10,000 population (p<0.01) by the end of the study period. CTR surgical procedures were approximately two-fold more common among females relative to males (64.9% vs. 35.1 respectively; p<0.01). Lastly, CTR procedures are increasingly being conducted in the outpatient setting while procedures in the inpatient setting have been declining steadily – the proportion of procedures performed in the outpatient setting increased from 13% to over 30% by 2010 (p<0.01).ConclusionOverall, CTR surgical-procedures are conducted at a rate of approximately 10 patients per 10,000 population annually with significant variation with respect to age and gender. CTR surgical procedures in ambulatory-care facilities may soon outpace procedure rates in the in-hospital setting.

Double crush syndrome due to plating of humeral shaft fracture.

Median nerve injury is rarely associated with the humeral shaft fracture. A Sixty two year old woman with a displaced humeral shaft fracture, developed a symptomatic carpal tunnel syndrome after plating with a screw protruding medially. 16 months later, the implants were removed and the symptoms gradually improved without carpal tunnel release surgery. A double crush syndrome resulted due to the proximal compression by the medially protruding screw and the distal compression by carpal tunnel. The proximal decompression produced by removal of the screw led to relief of the symptoms.

Median nerve injury caused by brachial plexus block for carpal tunnel release surgery.

Carpal tunnel release is required to treat patients with severe carpal tunnel syndrome. The regional anesthesia of the upper limb by brachial plexus block (BPB) may be a good alternative to general anesthesia for carpal tunnel release surgery, because it results in less complications. However, the regional anesthesia still has various side effects, such as hematoma, infection, and peripheral neuropathy. We hereby report a rare case of median nerve injury caused by BPB for carpal tunnel release.

Outcome analysis of limited open carpal tunnel release: A prospective study

Background: Carpal tunnel syndrome (CTS) is the most common peripheral compressive neuropathy, involving median nerve at the wrist. Traditionally, three different surgical techniques have been described open or standard, minimal invasive or limited open, and endoscopic surgeries. However, the results of each method are conflicting. The goal of our study was to assess the clinical outcome including complication rates following limited open carpal tunnel release. Patients and Methods: The study included patients with idiopathic CTS undergoing limited open carpal tunnel release surgery. The Boston Carpal Tunnel questionnaire was used to assess the symptom severity and functional status pre and post surgical interventions. Results: Twenty two patients (27 hands) underwent limited open carpal tunnel release, and all patients completed the questionnaire. The mean age of patients was 44.9 years with a mean duration of follow-up was 16.2 months. The average surgical wound length (scar length) was 2.7 cm. The median time to return to work was 14 days (range: 7-31). There was a significant improvement in pre to post operative symptom severity score (SSS) and functional status score (FSS). The statistical correlation was significant between pre and post operative SSS and FSS scores. One patient had a superficial infection which was treated conservatively. No patient had pillar pain, scar tenderness, and nerve injuries. Conclusion: The limited open carpal tunnel release surgery is the simple, safe, and effective mode of treatment.

Use of the Accordion Severity Grading System for negative outcomes of carpal tunnel syndrome

A universal classification of the negative outcomes of carpal tunnel release surgery does not, as yet, exist. In order to avoid the use of arbitrary factors we have applied the Accordion Severity Grading System, which uses rigorously defined qualitative terms to classify complications. It also provides a uniform manner for grading the severity of complications, enabling outcome comparisons between centres. We analysed the negative outcomes of 500 device-assisted carpal tunnel releases performed over a 2-year period in the author's department. In order to establish a standardised list of complications we used the terms employed within the guidelines of the American Academy of Orthopaedic Surgeons. Most of these terms were subsequently defined using the data variables and definitions taken from the American College of Surgeons National Surgical Quality Improvement Program or the Medical Subject Headings of the National Library of Medicine. We also adopted the quantitative severity weighting, as proposed by the Accordion system, in order to determine the postoperative morbidity index for our assisted carpal tunnel releases. The most common complications were pain and reversible damage to peripheral nerves. Other common negative events, other than complications, included hand weakness, which we classified as a sequela of the procedure, and incomplete retinaculum release, which we classified as failure to cure. The overall postoperative morbidity index for complications was 0.014. Although the Accordion system was developed for more complex procedures, it may also be adopted for carpal tunnel release surgery where it provides an objective and universal method for the classification of complications.

Influence of compensation status on time off work after carpal tunnel release and rotator cuff surgery: a meta-analysis

BackgroundThe assessment of post-surgical outcomes among patients with Workers’ Compensation is challenging as their results are typically worse compared to those who do not receive this compensation. These patients’ time to return to work is a relevant outcome measure as it illustrates the economic and social implications of this phenomenon. In this meta-analysis we aimed to assess the influence of this factor, comparing compensated and non-compensated patients.FindingsTwo authors independently searched MEDLINE (Ovid), Embase (Ovid), CINAHL, Google Scholar, LILACS and the Cochrane Library and also searched for references from the retrieved studies. We aimed to find prospective studies that compared carpal tunnel release and elective rotator cuff surgery outcomes for Workers’ Compensation patients versus their non-compensated counterparts. We assessed the studies’ quality using the Guyatt & Busse Risk of Bias Tool. Data collection was performed to depict included studies characteristics and meta-analysis. Three studies were included in the review. Two of these studies assessed the outcomes following carpal tunnel release while the other focused on rotator cuff repair. The results demonstrated that time to return to work was longer for patients that were compensated and that there was a strong association between this outcome and compensation status - Standard Mean Difference, 1.35 (IC 95%; 0.91-1.80, p < 0.001).ConclusionsThis study demonstrated that compensated patients have a longer return to work time following carpal tunnel release and elective rotator cuff surgery, compared to patients who did not receive compensation. Surgeons and health providers should be mindful of this phenomenon when evaluating the prognosis of a surgery for a patient receiving compensation for their condition.Type of study/level of evidenceMeta-analysis of prospective Studies/ Level III

Carpal Tunnel Release Surgery and Venous Hypertension in Early Hemodialysis Patients without Amyloid Deposits

Aim. Carpal tunnel syndrome (CTS) is one of the frequent problems of the patients who underwent hemodialysis (HD). The role of venous hypertension due to arteriovenous fistula (AVF) has not been clarified completely; therefore, we aimed to investigate the role of venous hypertension due to AVF in hemodialysis patients who had CTS. Patients and Methods. We included 12 patients who had been receiving HD treatment for less than 8 years and the newly diagnosed CTS patients with the same arm of AVF. All patients were diagnosed clinically and the results were confirmed by both nerve conduction studies and electromyography. Open carpal tunnel release surgery was performed on all of them. Venous pressure was measured in all patients before and after two weeks of surgery. Results. There were significant differences before and after the surgery with regard to pressures (P > 0.05). After the surgery, all carpal ligament specimens of the patients were not stained with Congo red for the presence of amyloid deposition. Conclusion. Increased venous pressure on the same arm with AVF could be responsible for CTS in hemodialysis patients. Carpal tunnel release surgery is the main treatment of this disease by reducing the compression on the nerve.

Pulmonary artery re-thrombosis following interruption of anti-thrombotic therapy for bilateral carpal tunnel release surgery: An update of current protocols

In the perioperative period, patients who are under anti-thrombotic therapy should be managed with care, although there is no clear consensus on this matter. For hand surgery, several authors have advocated no interruption of the anti-thrombotic therapy, but the choice differs between institutes according to protocols and surgeons' preference. We report a case of massive pulmonary embolism after stopping warfarin for carpal tunnel release in a patient with a previous history of pulmonary embolism. Although the patient recovered after thrombolytic therapy and intensive care unit (ICU) care, this case has struck the authors as a valuable lesson. In managing anti-thrombotic therapy, we should weigh the risks and benefits of the patients carefully before making a decision.

Carpal tunnel release surgery: small-area variation and impact of ambulatory surgery in the autonomous region of Valencia, Spain

ObjectiveThis study aimed to analyze variability in rates of carpal tunnel release surgery among the healthcare areas of the autonomous region of Valencia, and to evaluate the contribution of ambulatory surgery and referrals to private hospitals to the variability found. MethodsWe carried out a cross-sectional, population-based study, describing the rates of carpal tunnel release surgery, standardized by age and sex, among areas in the region of Valencia in 2006. The observed variation was then analyzed using small-area analysis methods. Data from hospital admissions, referrals to private hospitals, population statistics and hospital resources were used to construct standardized rates, and Spearman's correlation was used to test the association with surgical setting and hospital resources. ResultsThere were 8.2 carpal tunnel release surgeries per 10,000 inhabitants in the region of Valencia in 2006. Most (88.2%) of these interventions were performed as ambulatory surgery. After we excluded areas outside the 5th-95th percentiles, variation among areas was moderate and was similar for men and women. Variation was not associated with the proportion of the distinct surgical settings (admission to a public hospital, outpatient clinic, or referral to a private hospital) used in each area, or with the availability of resources. ConclusionsVariation in carpal tunnel release surgery among areas in the region of Valencia is moderate, but has a strong impact on the population because of the high prevalence of this disorder. This variation is not explained by the hospital resources available in each area or the surgical setting.

An Overview of Regular Dialysis Treatment in Japan (As of 31 December 2010)

A nationwide statistical survey of 4226 dialysis facilities was conducted at the end of 2010, and 4166 facilities (98.6%) responded. The number of new patients introduced into dialysis was 37,512 in 2010. This number has decreased for two consecutive years since it peaked in 2008. The number of patients who died in 2010 was 28,882, which has been increasing every year. The number of patients undergoing dialysis at the end of 2010 was 298,252, which is an increase of 7591 (2.6%) compared with that at the end of 2009. The number of dialysis patients per million at the end of 2010 was 2329.1. The crude death rate of dialysis patients in 2010 was 9.8%, and has been gradually increasing. The mean age of the new patients introduced into dialysis was 67.8 years and the mean age of the entire dialysis patient population was 66.2 years. Regarding the primary disease of the new patients introduced into dialysis, the percentage of patients with diabetic nephropathy was 43.6%, which is a slight decrease from that in the previous year (44.5%). Patients with diabetic nephropathy as the primary disease accounted for 35.9% of the entire dialysis patient population, which approaches the percentage of patients with chronic glomerulonephritis as the primary disease (36.2%). The percentage of patients who had undergone carpal tunnel release surgery (CTx) was 4.3%, which is a slight decrease from that at the end of 1999 (5.5%). The decrease in the percentage of patients who had undergone CTx was significant among the patients with dialysis durations of 20-24 years (1999, 48.0%; 2010, 23.2%). A total weekly Kt/V attributable to peritoneal dialysis and their residual functional kidney was 1.7 or higher for 59.4% of patients who underwent peritoneal dialysis.

Pressure–morphology relationship of a released carpal tunnel

We investigated morphological changes of a released carpal tunnel in response to variations of carpal tunnel pressure. Pressure within the carpal tunnel is known to be elevated in patients with carpal tunnel syndrome and dependent on wrist posture. Previously, increased carpal tunnel pressure was shown to affect the morphology of the carpal tunnel with an intact transverse carpal ligament (TCL). However, the pressure-morphology relationship of the carpal tunnel after release of the TCL has not been investigated. Carpal tunnel release (CTR) was performed endoscopically on cadaveric hands and the carpal tunnel pressure was dynamically increased from 10 to 120 mmHg. Simultaneously, carpal tunnel cross-sectional images were captured by an ultrasound system, and pressure measurements were recorded by a pressure transducer. Carpal tunnel pressure significantly affected carpal arch area (p < 0.001), with an increase of >62 mm(2) at 120 mmHg. Carpal arch height, length, and width also significantly changed with carpal tunnel pressure (p < 0.05). As carpal tunnel pressure increased, carpal arch height and length increased, but the carpal arch width decreased. Analyses of the pressure-morphology relationship for a released carpal tunnel revealed a nine times greater compliance than that previously reported for a carpal tunnel with an intact TCL. This change of structural properties as a result of transecting the TCL helps explain the reduction of carpal tunnel pressure and relief of symptoms for patients after CTR surgery.

Poster 169 Trends in Ambulatory Carpal Tunnel Release Surgery in the U.S. 1996-2006

Poster 169 Trends in Ambulatory Carpal Tunnel Release Surgery in the U.S. 1996-2006

Incidence of Carpal Tunnel Release: Trends and Implications Within the United States Ambulatory Care Setting

To investigate the changes, trends, and implications of carpal tunnel release (CTR) surgery within an ambulatory setting over the past decade in the United States. We undertook an analysis of ambulatory surgery center CTR cases using data from the National Survey of Ambulatory Surgery. The Centers for Disease Control and Prevention carried out this survey in 1996, and again in 2006. We searched the cases with the procedure codes indicative of CTR. The number of CTR procedures increased by 38% (from 360,000 to 577,000) between 1996 and 2006. In 1996, 16% of all ambulatory CTRs were performed in freestanding ambulatory surgery centers (hospital-based centers were 84%), and the proportion increased to 49% in 2006. By 2006, greater than 99% of CTRs were performed in an ambulatory setting. There was a significant increase in women aged 50 to 59 years of age undergoing CTR. The minimal invasiveness of CTR combined with the advent of ambulatory care facilities has made CTR a predominantly outpatient procedure. In contrast to other reports, our study demonstrated a higher incidence of CTR within the United States in 2006 compared with 1996. Elderly women, in particular, with CTS were 3 times more likely to be treated surgically than other age groups. Further study is needed to better define factors influencing CTR indications. Prognostic II.

Chronic post-operative pain one year after carpal tunnel release surgery

Belze, O.; Remérand, F.; Laulan, J.; Augustin, B.; Laffon, M.; Fusciardi, J. Author Information