Effectiveness Of Carpal Tunnel Release Research Articles

Trial of ultrasound guided carpal tunnel release versus traditional open release (TUTOR).

Background:Carpal tunnel release (CTR) is a surgical treatment option for patients with carpal tunnel syndrome (CTS) symptoms that are unresponsive to conservative treatment. Most patients experience symptomatic relief after CTR regardless of the surgical technique. However, direct comparisons of the safety and effectiveness between CTR surgical techniques are limited. The purpose of this randomized controlled trial is to compare the safety and effectiveness of CTR with ultrasound guidance (CTR-US) versus mini-open CTR (mOCTR) in subjects with symptomatic CTS.Design and methods:TUTOR (Trial of Ultrasound guided CTR versus Traditional Open Release) is a randomized controlled trial in which 120 subjects at up to 12 sites in the United States will be randomized (2:1) to receive CTR-US or mOCTR. The primary endpoint of the study is the percentage of patients who return to normal daily activities within 3 days of the procedure. Secondary endpoints of the study are median time to return to normal daily activities, percentage of patients who return to work within 3 days of the procedure, median time to return to work, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) change score at 3 months, BCTQ Functional Status Scale (BCTQ-FSS) change score at 3 months, Numeric Pain Scale change score at 3 months, EuroQoL-5 Dimension 5-Level (EQ-5D-5L) change score at 3 months, and the incidence of device- or procedure-related adverse events at 3 months. Patient follow-up in this trial will continue for 1 year.Ethics and dissemination:This study was approved by a central institutional review board and ongoing trial oversight will be provided by a data safety monitoring board (DSMB). The authors intend to report the results of this trial at medical conferences and peer-reviewed journals. The outcomes of TUTOR will have important clinical and economic implications for all stakeholders involved in treating patients with CTS.Study registration:ClinicalTrials.gov (https://clinicaltrials.gov): NCT05405218.Level of evidence:1

The effect of carpal tunnel release on health-related quality of life of 2346 patients over a 5-year period.

In this prospective cohort study, the health-related quality of life (HRQoL) from a societal perspective of carpal tunnel syndrome (CTS) patients was determined and compared with other diseases. In addition, the effect of carpal tunnel release (CTR) was analysed 6weeks postoperatively with regard to mean EQ-5D index value improvement, side-effects of surgery and cost per quality adjusted life year (QALY) gained. We found a baseline mean EQ-5D index value of 0.75 (SD: 0.23), comparable with values seen in other disease like breast cancer, diabetes and asthma. Furthermore, we found that CTR improved HRQoL substantially 6weeks postoperatively (mean + 0.12, SD: 0.22) and significantly reduced symptom reporting (mean -52%, SD: 53) with a cost per QALY gained of €396.05. In conclusion, CTS has a comparable impact on quality of life as compared with other diseases, and CTR has the potential to substantially improve patient's HRQoL at a fairly modest cost.Level of evidence: III.

Modification of intra-carpal tunnel pressure after Z-lengthening of the transverse carpal ligament

BackgroundFlexor retinaculum reconstruction techniques or simply Flexor Retinaculum Z-lengthening have been proposed to preserve Flexor Retinaculum continuity after carpal tunnel release. Their effectiveness is based solely on symptom relief. There has been no analysis of the effects on intra-carpal tunnel pressure of Flexor Retinaculum-lengthening techniques. Objective was to compare intra-carpal tunnel pressure outcomes between complete division and Z-lengthening of the Retinaculum in a cadaveric model of carpal tunnel release.MethodsExperimental study of carpal tunnel pressure after surgical Flexor Retinaculum modification in 10 fresh-frozen forearm and hand cadaveric specimens. The Kyphon™ Balloon Kyphoplasty system was used to measure the pressure before and after infusing 1, 2, 3, 4 and 5 ml of saline solution when untreated (Flexor Retinaculum continuity stage I), when Z-lengthened (Flexor Retinaculum continuity stage II), and after complete Flexor Retinaculum division (Flexor Retinaculum continuity stage III).FindingIntra-carpal tunnel pressure increased with larger volume of infused saline solution, although mean pressures were lower after Z lengthening or complete division of the Retinaculum than at baseline. Analysis of linear regression coefficients indicated significant differences as a function of FR continuity stage (F(2,18) = 18.38, p < 0.001), while the Bonferroni test revealed significant differences in slopes between stages I and III (p = 0.003), between stages I and II (p < 0.02), but not between stages II and III (p > 0.05).InterpretationThe effectiveness of carpal tunnel release and the reduction in intra-carpal tunnel pressures obtained by Z-lengthening of the FR were similar to those observed after its complete division, while preserving FR continuity.

Patient-Generated Actigraphy Data as a Novel Outcomes Instrument in Carpal Tunnel Syndrome.

Currently, we lack objective measures to quantify outcomes in carpal tunnel syndrome. Instead, surgeons rely on patient-reported outcomes measures (PROMs) to assess the effect of carpal tunnel release (CTR). We assessed the validity and reliability of wearable activity monitors to objectively characterize the functional and sleep impact of CTR. We hypothesized that actigraphy could detect changes in sleep and activity and would demonstrate short-term impairment due the operative procedure. This pilot, prospective, cohort study compared validated PROMS with actigraphy data obtained via wearable activity monitors (ActiGraph Link; ActiGraph Corp, Pensacola, Fla). Subjects completed baseline questionnaires and wore their device for 1 week preoperatively as a baseline. Subjects then underwent open CTR, wearing actigraphy devices for 4 weeks and completing questionnaires at 2 and 4 weeks postoperatively. Preintervention and postintervention data were compared using paired-sample t test. The Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire data were analyzed in accordance with published PROMIS scoring manuals and raw scores were converted to standardized T scores. Twenty subjects (5 males, 15 females) with moderate or severe carpal tunnel syndrome were enrolled. The mean age was 57.7 years. The PROMIS 29 average cumulative T score was 42.9 with average change of -0.072 preoperatively versus postoperatively. Average sleep disturbance T score was 38.9 preoperatively and 41.4 postoperatively. There was no statistically significant difference in T score in any domain. The mean actigraphy activity data demonstrated near immediate return to baseline activity. Actigraphy sleep data demonstrate improvement in sleep fragmentation and decreased duration of awakenings. Overall, patient-generated data detected differences in sleep and activity preoperatively versus postoperatively and demonstrated only a short period of activity disruption after CTR, which may be used when counseling patients. These data support actigraphy as a viable adjunct to traditional PROMS to evaluate the impact of surgical intervention and therefore may be useful in the study of other diseases affecting the upper extremity.

Treatment outcome in patients with clinically defined carpal tunnel syndrome but normal electrodiagnostic test results: a randomized controlled trial

Little is known about treatment effect of carpal tunnel release in patients with clinically defined carpal tunnel syndrome (CTS), but normal electrodiagnostic test results (EDX). The aim of this study was to determine whether this category of patients will benefit from surgical treatment. 57 patients with clinically defined CTS and normal EDX were randomized for surgical treatment (n=39) or non-surgical treatment (n=18). A six-point scale for perceived improvement as well as the Boston Carpal Tunnel Questionnaire was completed at baseline and at follow-up after 6months. A significant improvement of complaints was reported by 70.0% of the surgically treated patients and 39.4% reported full recovery 6months after surgery. Furthermore, both Functional Status Score and Symptom Severity Score improved significantly more in the surgically treated group (p=0.036 and p<0.001, respectively). This study demonstrates that most patients with clinically defined CTS and normal EDX results will benefit from carpal tunnel release. Therefore, this group of CTS patients must not a priori be refrained from surgery.

Prospective Evaluation of Sleep Improvement Following Carpal Tunnel Release Surgery

Sleep disturbance due to nighttime awakening is a well-documented symptom of carpal tunnel syndrome. While relief of nighttime waking following carpal tunnel release (CTR) has been demonstrated, the effect of CTR on overall sleep quality has not been fully investigated. We hypothesized that CTR would result in significant improvement in overall sleep quality as well as patients' overall satisfaction with their sleep habits. Cases of carpal tunnel syndrome with positive nerve studies, and treated with CTR, were prospectively enrolled. Demographic data, electromyography (EMG) severity, Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, and Insomnia Severity Index (ISI) scale data were collected. A total of 398 patients were enrolled, with 99% available at 2 weeks and 64% available at 3-month final follow-up. At final follow-up, average Quick Disabilities of the Arm, Shoulder, and Hand score improved significantly from the preoperative value. Average ISI score on all 7 sleep categories on the survey improved significantly from before surgery to the first postoperative visit. However, the total ISI score did not further improve significantly between the 2-week and the 3-month postoperative visits. The ISI score improvements did not correlate with EMG severity. Patients undergoing CTR demonstrated significant improvement in mean scores for 7 aspects of sleep quality. Sleep improvement was unrelated to preoperative EMG severity and was experienced within 2 weeks of surgery. Therapeutic II.

The Effect of Carpal Tunnel Release on Neuropathic Pain in Carpal Tunnel Syndrome.

Purpose The aim of this study was to determine the risk factors of neuropathic pain (NP) in the patient with carpal tunnel syndrome (CTS) before and after the carpal tunnel release. Materials and Methods One hundred and two CTS patients were enrolled in the study. The pain score was measured by the visual analogue score. NP was determined by the painDETECT (PD) questionnaire. All subjects were divided into 3 groups at 12 weeks after surgery: an Improved, Unchanged, and Worsened group. The risk factors of worsening NP after surgery were evaluated. Results We found that 36% and 18% of patients with CTS had neuropathic pain before and 12 weeks after surgery, respectively, and pain was significantly stronger than in those without NP. The PD score of eight hands worsened after surgery. In the “Improved group,” the average age at the surgery was younger and the pain score was lower than in the “Unchanged group.” Conclusions. The surgery was very effective on NP of CTS; however, the PD in 7% of hands worsened after surgery. Risk factors before surgery that predicted worse NP after surgery were found to be a younger age, weaker pain, and the absence of night pain.

The Effect of Carpal Tunnel Release on Typing Performance

To describe the effect of carpal tunnel release (CTR) on typing performance. We prospectively studied 27 patients undergoing open CTR. Patient demographics and clinical characteristics including nerve conduction studies, electromyography results, and duration of symptoms were collected. Before surgery and at 8 time points after surgery, ranging from 1 to 12 weeks, typing performance for an approximately 500-character paragraph was assessed via an on-line platform. The Michigan Hand Questionnaire (MHQ) and the Boston Carpal Tunnel Questionnaire functional component (BCTQ-F) and symptom severity component (BCTQ-S) component were completed before surgery and at 1, 3, 6, and 12 weeks after surgery. We used repeated-measures analyses of variance and follow-up dependent-samples ttests to analyze change in typing performance across sessions, and linear regressions to assess relationships between typing performance and demographic and outcome measures. We compared typing speed with the MHQ, BCTQ-F, and BCTQ-S using the Pearson correlation test. Average typing speed decreased significantly from 49.7 ± 2.7 words per minute (wpm) before surgery to 45.2 ± 3.1 wpm at 8 to 10 days after surgery. Mean typing speed for the group exceeded the preoperative value between weeks 2 and 3, with continued improvement to 53.5 ± 3.5 wpm at 12 weeks after surgery. No clinical or demographic variables were associated with the rate of recovery or the magnitude of improvement after CTR. The MHQ, BCTQ-F, and BCTQ-S each demonstrated significant improvement from preoperative values over the 12-week period. The MHQ and BCTQ-F scores correlated well with typing speed. On average, typing speed returned to preoperative levels between 2 and 3 weeks after CTR and typing speed showed improvement beyond preoperative levels after surgery. The MHQ and BCTQ-F correlate well with typing speed after CTR. Prognostic IV.

Three-Dimensional Carpal Kinematics after Carpal Tunnel Release.

Carpal tunnel release (CTR) has been shown to change carpal arch morphology. However, the effect of CTR on the three-dimensional kinematics of the carpal bones has not been demonstrated. This study examined whether release of the transverse carpal ligament (TCL) would alter the three-dimensional kinematics of the carpus, specifically the bony attachments of the TCL. The in vitro kinematics of the carpus was studied in five fresh-frozen cadaveric wrists before and after CTR using three-dimensional computed tomography. The specimens were evaluated in three positions: neutral, 60 degrees of flexion, and 60 degrees of extension. The data indicate that carpal arch width increases significantly in all positions after CTR as measured between the trapezium and hamate. Second, the trapezium-hamate distance increases in both a translational and rotational component after CTR. Additionally, the pisiform rotates away from the triquetrum after CTR. Carpal kinematics is significantly altered with a CTR, especially on the ulnar side of the wrist. Although the kinematic changes are small, they may be clinically significant and potentially responsible for pillar pain or postoperative loss of grip strength.

EVIDENCE OF IMPROVEMENT IN DISTAL CONDUCTION OF ULNAR NERVE SENSORY FIBERS AFTER CARPAL TUNNEL RELEASE

The aim of this study was to verify any effect of carpal tunnel release (CTR) on distal ulnar nerve conduction findings, using the database of a previous study performed to establish a protocol for CTR outcome. The motor and sensory ulnar distal conduction findings of 251 consecutive hands belonging to 217 patients (175 women and 42 men; mean age, 55.6 years) with idiopathic carpal tunnel syndrome (CTS) were reanalyzed before and 1 and 6 months after CTR. Before surgery, 115 hands (45.8%) showed reduction of ulnar nerve sensory action potential (SAP) amplitude; this number was reduced significantly to 85 (33.9%) after CTR. The SAP amplitude and sensory conduction velocity values of the ulnar nerve showed significant improvement 1 month after CTR; SAP amplitude values showed further significant improvement 6 months after CTR. Patients' ages and occupations were independent predictors of reduced baseline SAP amplitudes of the ulnar nerve in CTS. These results demonstrate an improvement in conduction values in sensory ulnar fibers in a percentage of patients with CTS after CTR, providing further support for the conclusion that in CTS ulnar fibers may be subject to compressive forces in the Guyon canal as a consequence of high pressure in the carpal tunnel.

A prospective, longitudinal outcome study of patients with carpal tunnel surgery and the relationship of body mass index.

This study investigated whether body mass index (BMI) was associated with effectiveness of carpal tunnel release as measured by physical and self-assessment tests. This prospective, longitudinal study was conducted from March 2001 to March 2003 using 598 cases (hands) diagnosed with carpal tunnel syndrome and scheduled for surgery at The Curtis National Hand Center, Baltimore, Maryland, and at the Pulvertaft Hand Centre, Derby, England. Body mass index was calculated, and demographic, clinical, and functional data were collected preoperatively and at 6-month follow-up. Grip, pinch, and Semmes-Weinstein scores were measured preoperatively and at 6-month follow-up. Levine-Katz self-assessment scores for symptom severity and functional status were measured preoperatively and at 6-month follow-up. Grip and pinch increased, whereas Semmes-Weinstein, symptom severity, and functional scores decreased by 6-month follow-up. Cases with BMI >35 had lower grip strength and higher symptom severity in males and higher functional status in both sexes pre- and postoperatively compared to normal-weight BMI cases. BMI had no relationship to patient satisfaction. Although morbidly obese cases did worse on some physical and self-assessment tests compared to normal BMI cases preoperatively, all improved to the same extent postoperatively regardless of BMI.

The effect of age and gender upon symptoms and surgical outcomes in carpal tunnel syndrome

There is conflicting evidence regarding the effectiveness of carpal tunnel release in older patients. This is a prospective study which evaluates the impact of age and gender upon symptoms, self-reported disability and surgical outcome in a series of 97 patients with carpal tunnel syndrome. Symptom severity, hand function and patient satisfaction were assessed using the Boston Carpal Tunnel Questionnaire and the Patient Evaluation Measure. A statistical correlation of age and gender with symptoms, hand function and surgical outcome was performed with questionnaires administered before open carpal tunnel decompression and 6 months after surgery. Women reported greater pre-operative symptoms and disability than men, but there was no gender-related difference in surgical outcome or patient satisfaction. There was no difference in surgical outcome between patients 60 and 70 years of age and younger patients. The majority of patients over the age of 70 reported an improvement in symptoms and function, but they were less satisfied with their treatment than younger patients. Some patients had problems with persistent numbness and loss of dexterity following surgery. The outcome of carpal tunnel release in terms of improvement in the symptom and functional scores is sufficient to justify surgery in the elderly, but surgical outcomes are less predictable than in younger patients and we recommend that this is explained to them when obtaining consent for surgery.

Comparison of SNAP and CMAP before and after carpal tunnel release: a clinical study

目的 比较腕管综合征术前和正中神经松解术后(术中)两者感觉神经动作电位(sensorynerve action potential,SNAP)与复合肌肉动作电位(compound muscle action potential,CMAP)检测结果的差异.方法对20例腕管综合征患者,术中在切开屈肌支持带及正中神经松解术后,分别测定(1)拇短展肌的CMAP;(2)刺激示、中指,于腕部记录正中神经的SNAP;(3)刺激环指,于腕部分别记录正中神经和尺神经的SNAP.将三者结果与术前的相应数据行统计学分析.结果(1)术前拇短展肌CMAP的潜伏期小于4.3ms,术后其潜伏期、波幅与术前相比差异无统计学意义(P＞0.05).(2)术后2～4指SNAP的潜伏期比术前平均缩短5％、波幅增加13％左右,两者相比差异均有统计学意义(P＜0.01).结论腕管综合征手术中,在正中神经松解术后行SNAP检测较CMAP检测的结果更为敏感和准确。

On the uniformity of cardiopulmonary exercise testing in chronic heart failure

Sleep disturbance due to nighttime awakening is a well-documented symptom of carpal tunnel syndrome. While relief of nighttime waking following carpal tunnel release (CTR) has been demonstrated, the effect of CTR on overall sleep quality has not been fully investigated. We hypothesized that CTR would result in significant improvement in overall sleep quality as well as patients’ overall satisfaction with their sleep habits.Cases of carpal tunnel syndrome with positive nerve studies, and treated with CTR, were prospectively enrolled. Demographic data, electromyography (EMG) severity, Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, and Insomnia Severity Index (ISI) scale data were collected.A total of 398 patients were enrolled, with 99% available at 2 weeks and 64% available at 3-month final follow-up. At final follow-up, average Quick Disabilities of the Arm, Shoulder, and Hand score improved significantly from the preoperative value. Average ISI score on all 7 sleep categories on the survey improved significantly from before surgery to the first postoperative visit. However, the total ISI score did not further improve significantly between the 2-week and the 3-month postoperative visits. The ISI score improvements did not correlate with EMG severity.Patients undergoing CTR demonstrated significant improvement in mean scores for 7 aspects of sleep quality. Sleep improvement was unrelated to preoperative EMG severity and was experienced within 2 weeks of surgery.Therapeutic II.

CAN THE OUTCOME OF CARPAL TUNNEL RELEASE BE PREDICTED?

Between 1994 and 1996 we performed a prospective study on the effect of carpal tunnel release on the health status of 96 patients. The Nottingham Health Profile, a validated global scoring system, was used to assess quality of life before, and at 4 months after surgery. Carpal tunnel syndrome had a significant impact on the health status of our patients. There were significant improvements in the scores for pain, energy and sleep. Patients who were dissatisfied following surgery had significantly higher pre-operative scores, indicating poor perceived health status. Our findings show that outcome assessment tools have predictive value in identifying patients who may not benefit from surgery, or in whom a poor result might be anticipated.

Carpal tunnel syndrome: Associated abnormalities in ulnar nerve function and the effect of carpal tunnel release on these abnormalities

Twenty of 59 hands (34%) of patients with carpal tunnel syndrome had abnormalities in sensibility testing of both median and ulnar nerves by either two-point discrimination, Semmes-Weinstein monofilament testing, or both. Before surgery, 53% of patients complained of paresthesias and/or numbness in ulnar nerve distribution. Eighty percent of the hands had abnormal Semmes-Weinstein monofilament testing of the ulnar nerve. Thirty-five percent had abnormal two-point discrimination. Forty-one percent had abnormal electromyographic testing of the ulnar nerve. All hands had median nerve decompression alone. Guyon's canal was not released. After surgery, 89% of patients had improvement in paresthesias and/or numbness of the ulnar nerve. Ninety-four percent had improvement in Semmes-Weinstein monofilament testing. Eighty-six percent had improvement in two-point discrimination. Patients with a residual abnormality in ulnar nerve sensibility also had continued abnormality in median nerve sensibility. A significant percentage of patients with carpal tunnel syndrome also have signs and symptoms of ulnar nerve compression. Most improved with carpal tunnel release alone.