Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis

New Frontiers in Wide-Awake Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery.

SUMMARY

Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.

The application of human reliability analysis to carpal tunnel decompression

INTRODUCTION

Many surgical procedures are prone to human error, particularly in the learning phase of skills acquisition. Task standardisation has been suggested as an approach to reducing errors, but it fails to account for the human factors associated with learning. Human reliability analysis (HRA) is a structured approach to assess human error during surgery. This study used HRA methodologies to examine skills acquisition associated with carpal tunnel decompression.

METHODS

The individual steps or subtasks required to complete a carpal tunnel decompression were identified using hierarchical task analysis (HTA). The systematic human error reduction and prediction approach (SHERPA) was carried out by consensus of subject matter experts. This identified the potential human errors at each subgoal, the level of risk associated with each task and how these potential errors could be prevented.

RESULTS

Carpal tunnel decompression was broken down into 46 subtasks, of which 21 (45%) were medium risk and 25 (55%) were low risk. Of the 46 subtasks, 4 (9%) were assigned high probability and 18 (39%) were assigned medium probability. High probability errors (>1/50 cases) included selecting incorrect tourniquet size, failure to infiltrate local anaesthetic in a proximal-to-distal direction and completion of the World Health Organization (WHO) surgical sign-out. Three (6%) of the subtasks were assigned high criticality, which included failure to aspirate before anaesthetic injection, whereas 21 (45%) were assigned medium criticality. Remedial strategies for each potential error were devised.

CONCLUSIONS

The use of HRA techniques provides surgeons with a platform to identify critical steps that are prone to error. This approach may improve surgical training and enhance patient safety.

Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis

PURPOSE

Wide-Awake Local Anaesthesia No Tourniquet (WALANT), a groundbreaking anaesthetic technique resurging in practice, warrants a comprehensive safety analysis for informed adoption. Our study aimed to identify complications/side effects of WALANT upper limb procedures through a systematic review and meta-analysis.

METHODS

This PROSPERO-registered study was performed with strict adherence to PRISMA guidelines. Embase, OVIDMedline, Cochrane, Web of Science, and Scopus databases were searched until February 2023. Inclusion criteria involved English articles, reporting complications/side effects in primary WALANT upper limb surgeries. Outcomes included all complications and side effects, data on the anaesthetic mixture, publication year/location, study type, and procedures performed. The meta-analysis employed the Freeman-Tukey Double Arcsine Transformation, computed I2 statistics, and utilized common or random effects models for pooled analysis.

RESULTS

2002 studies were identified; 79 studies met the inclusion criteria representing 15,595 WALANT patients. A total of 301 patients had complications, and the meta-analysis using a random effects model provided a complication rate of 1.7% (95% CI: 0.93-2.7%). The most reported complications were superficial infection (41%, n = 123/300), other/specified (12%, n = 37/300), and recurrent disease (6.7%, n = 20/300). A decade-by-decade analysis revealed no statistically significant difference in complication rates spanning the last three decades (p = 0.42). Adding sodium bicarbonate to the anaesthetic solution significantly reduced postoperative complications (p = 0.025).

CONCLUSION

WALANT has a low overall complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications when sodium bicarbonate is added to the anaesthetic solution. Our findings support the safety of WALANT in upper limb procedures.

REGISTRATION

PROSPERO: CRD42023404018.

Direct Variable Cost Comparison of Endoscopic Versus Open Carpal Tunnel Release: A Time-Driven Activity-Based Costing Analysis

INTRODUCTION

To improve the delivery of value-based health care, a deeper understanding of the cost drivers in hand surgery is warranted. Time-driven activity-based costing (TDABC) offers a more accurate estimation of resource utilization compared with top-down accounting methods. This study used TDABC to compare the facility costs of open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR).

METHODS

We identified 845 consecutive, unilateral carpal tunnel release (516 open, 329 endoscopic) surgeries performed at an orthopaedic specialty hospital between 2015 and 2021. Itemized facility costs were calculated using a TDABC algorithm. Patient demographics, comorbidities, surgical characteristics, and itemized costs were compared between OCTR and ECTR. Multivariate regression was used to determine the independent effect of endoscopic surgery on true facility costs.

RESULTS

Total facility costs were $352 higher in ECTR compared with OCTR ($882 versus $530). ECTR cases had higher personnel costs ($499 versus $420), likely because of longer surgical time (15 versus 11 minutes) and total operating room time (35 versus 27 minutes). ECTR cases also had higher supply costs ($383 versus $110). Controlling for demographics and comorbidities, ECTR was associated with an increase in personnel costs of $35.74 (95% CI, $26.32 to $45.15), supply costs of $230.28 (95% CI, $205.17 to $255.39), and total facility costs of $265.99 (95% CI, $237.01 to $294.97) per case.

DISCUSSION

Using TDABC, ECTR was 66% more costly to the facility compared with OCTR. To reduce the costs related to endoscopic surgery, efforts to decrease surgical time and negotiate lower ECTR-specific supply costs are warranted.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level II.

State of the art review. Complications after carpal tunnel release

Carpal tunnel release (CTR) is the most performed surgery of the upper extremity. It is effective but not without complications. This state-of-the-art review covers most common intra- and postoperative complications after CTR. As endoscopic carpal tunnel release (ECTR) has developed over time, severe complications, such as nerve lesions, have diminished. ECTR still has a higher risk on transient nerve lesions. Open CTR on the other hand has a higher incidence of wound-related problems, including scar tenderness, irrespective of incision used. Most complications, such as pillar pain and infection, are ill-defined in the literature, leaving the exact incidence unknown and proposing challenges in treatment. The same is true for failure of treatment. Optimizing the length and location of incisions has played a vital role in reducing intra- and postoperative complications in CTR. It is expected that technical advances, such as ultrasound-guided percutaneous carpal tunnel release, will continue to play a role in the future.Level of evidence: V.

Revision Carpal Tunnel Release Following Endoscopic Compared With Open Decompression

Importance

Carpal tunnel release (CTR) technique may influence the likelihood of revision surgery. Prior studies of revision CTR following endoscopic CTR (ECTR) compared with open CTR (OCTR) have been limited by sample size and duration of follow-up.

Objective

To estimate the incidence of revision CTR following ECTR compared with OCTR in a national cohort.

Design, Setting, and Participants

This retrospective cohort study used data from the US Veterans Health Administration. Participants included all adults (age ≥18 years) undergoing at least 1 outpatient CTR from October 1, 1999, to May 20, 2021. Data were analyzed from May 21, 2021, to November 27, 2023.

Exposure

Index CTR technique.

Main Outcomes and Measures

The primary outcome was time to revision CTR, defined as repeat ipsilateral CTR during the study period. Secondary outcomes were indications for revision, findings during revision, and additional procedures performed during revision.

Results

Among 134 851 wrists from 103 455 patients (92 510 [89.4%] male; median [IQR] age, 62 [53-70] years) undergoing at least 1 CTR, 1809 wrists underwent at least 1 revision at a median (IQR) of 2.5 (1.0-3.8) years. In competing-risks analysis, the cumulative incidence of revision was 1.06% (95% CI, 0.99%-1.12%) at 5 years and 1.59% (95% CI, 1.51%-1.67%) at 10 years. ECTR was associated with increased hazard of revision CTR compared with OCTR (adjusted hazard ratio [aHR], 1.56; 95% CI, 1.34-1.81; P < .001). The risk difference for revision CTR associated with ECTR compared with OCTR was 0.57% (95% CI, 0.31%-0.84%) at 5 years (number needed to harm, 176) and 0.72% (95% CI, 0.36%-1.07%) at 10 years (number needed to harm, 139). Regardless of index CTR technique, the most common indication for revision was symptom recurrence (1062 wrists [58.7%]). A reconstituted transverse carpal ligament (TCL) was more common after ECTR compared with OCTR, whereas scarring of the overlying tissues and of the median nerve itself were more common following OCTR. Incomplete transverse-carpal-ligament release was observed in 251 of the wrists undergoing revision CTR (13.94%) and was more common among revisions following ECTR (odds ratio, 1.62; 95% CI, 1.11-2.37; P = .01).

Conclusions and Relevance

In this cohort study of revision CTR in the Veterans Health Administration, ECTR was associated with increased risk of revision compared with OCTR, but the absolute risk was low regardless of technique. Intraoperative findings at revision varied significantly according to index CTR technique.

Carpal tunnel syndrome

Median neuropathy at the wrist, commonly referred to as carpal tunnel syndrome (CTS), is the most common entrapment neuropathy. It is caused by chronic compression of the median nerve at the wrist within the space-limited carpal tunnel. Risk factors that contribute to the etiology of compression include female gender, obesity, work-related factors, and underlying medical conditions, such as hypothyroidism, pregnancy, and amyloidosis. The diagnosis is made on clinical grounds, although these can be confounded by anatomical variations. Electrodiagnostic studies, which are specific and sensitive in diagnosing CTS, support the diagnosis; however, a subgroup may present with normal results. The advent of imaging techniques, including ultrasound and MRI, further assists the diagnostic process. The management of CTS is divided into the nonsurgical approaches that include hand therapy, splinting and corticosteroid injection, and surgical decompression of the carpal tunnel. Although several surgical techniques have been developed, no one method is more effective than the other. Each of these management approaches are effective at providing symptom relief and are utilized at different severities of the condition. There is, however, a lack of consensus on standardized diagnostic criteria, as well as when and to whom to refer patients for surgery.

Incidence and Risk Factors for Revision Within 1 Year of Primary Carpal Tunnel Release

BACKGROUND

The annual volume of carpal tunnel release (CTR) in the United States has been estimated to be 577 000 per year. Our objectives were to evaluate the incidence and risk factors for revision CTR within 1 year of primary CTR.

METHODS

We identified all adult patients undergoing primary CTR from October 2015 to September 2019 in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology (CPT) codes. We used the CPT modifier codes to determine laterality of index and revision procedures. We estimated multivariable hierarchical logistic regression models to evaluate risk factors for revision CTR within 1 year.

RESULTS

Of the 80 423 primary CTR procedures, 178 (0.22%) underwent a revision CTR within 1 year of the index surgery. The mean (SD) age of the entire cohort was 58.69 (14.43) years, 61.1% were women, 73.2% were non-Hispanic white, 42.9% were covered through private insurance, and 9.5% had diabetes mellitus. Workers' compensation insurance (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.13-2.98, P = .02) and simultaneous bilateral CTR (OR = 14.91, 95% CI, 9.62-23.12, P < .001) were associated with revision CTR within 1 year of the index procedure. No models demonstrated an association between endoscopic technique or surgeon volume and revision CTR.

CONCLUSIONS

The incidence of revision CTR within 1 year was lower than that previously reported. Patients covered by workers' compensation and those undergoing simultaneous bilateral CTR had higher likelihood of a revision CTR within 1 year, whereas endoscopic technique and surgeon volume were not associated with revision CTR within 1 year.

Body Mass Index as a Predictor for Postoperative Complications Following Carpometacarpal Arthroplasty

Purpose

Carpometacarpal (CMC) arthroplasty is an effective surgical treatment to relieve pain and improve function for osteoarthritis of the CMC joint. The association between body mass index (BMI) and postoperative complications has been studied for other orthopedic procedures, including total knee arthroplasty, total hip arthroplasty, and total shoulder arthroplasty. However, BMI has not been studied as a risk factor for postoperative complications following CMC arthroplasty. The purpose of this study was to determine the postoperative complications associated with different categories of BMI following CMC arthroplasty. We hypothesized that increasing BMI is associated with more severe complications.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent CMC arthroplasty between 2015 and 2020. Patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. Patients were stratified into cohorts based on BMI as follows: underweight (BMI < 18.5 kg/m2), normal/reference (18.5 kg/m2 ≤ BMI < 30.0 kg/m2), obese (30.0 kg/m2 ≤ BMI < 35.0 kg/m2), severely obese (35.0 kg/m2 ≤ BMI < 40.0 kg/m2), and morbidly obese (BMI ≥ 40.0 kg/m2). Multivariate logistic regression was used to identify postoperative complications associated with each cohort.

Results

In total, 6,432 patients were included in this study: 3,622 (56.3%) patients were included in the normal/reference cohort, 77 (1.2%) patients were included in the underweight cohort, 1,479 (23.0%) patients were included in the obese cohort, 718 (11.2%) patients were included in the severely obese cohort, and 536 (8.3%) patients were included in the morbidly obese cohort. The obese cohort was independently associated with a higher rate of superficial incisional surgical-site infection (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.00-4.44; P = .050). The morbidly obese cohort was independently associated with readmission (OR, 3.35; 95% CI, 1.15-9.74; P = .026) and reoperation (OR, 3.40; 95% CI, 1.04-1.11; P = .043).

Conclusions

Morbid obesity is a clinically significant predictor for readmission and reoperation within 30 days following CMC arthroplasty. Obesity is a clinically significant predictor for superficial incisional surgical-site infection within 30 days following CMC arthroplasty.

Clinical relevance

A better understanding of BMI as a risk factor for postoperative complications may allow surgeons to improve preoperative risk stratification and patient counseling.

Type of study/level of evidence

Prognostic III.

Acute Carpal Tunnel Syndrome: Early Nerve Decompression and Surgical Stabilization for Bony Wrist Trauma

We undertook this study to investigate the outcomes of surgical treatment for acute carpal tunnel syndrome following our protocol for concurrent nerve decompression and skeletal stabilization for bony wrist trauma to be undertaken within 48 hours.

Early Postoperative Recovery after Modified Ultra-Minimally Invasive Sonography-Guided Thread Carpal Tunnel Release

Thread carpal tunnel release (TCTR) has been reported to be safe and effective for the treatment of carpal tunnel syndrome. The aim of this study is to evaluate the modified TCTR for safety, efficacy, and postoperative recovery. Seventy-six extremities in 67 patients undergoing TCTR were analyzed pre- and postoperatively using clinical parameters and patient-reported outcome measures. Twenty-nine men and 38 women with a mean age of 59.9 ± 18.9 years underwent TCTR. The mean postoperative time to resume activities of daily living was 5.5 ± 5.5 days, analgesia was completed after 3.7 ± 4.6 days, and return to work was achieved after a mean of 32.6 ± 15.6 days for blue-collar workers and 4.6 ± 4.3 days for white-collar workers. The Boston Carpal Tunnel Questionnaire (BCTQ) and Disability of Arm, Shoulder, and Hand (DASH) scores were comparable with previous studies. Overall, two persistent compressions and one recurrence required open reoperation (3.9%). All three had been operated in the initial phase, and none required reoperation after an additional safety step was introduced. No other complications occurred. TCTR surgery appears to be a safe and reliable technique with almost no wound and scarring and a potentially faster recovery time than open techniques. Although our technical modifications may reduce the risk of incomplete release, TCTR requires both ultrasound and surgical skills and has a considerable learning curve.

Iatrogenic median and ulnar nerve injuries during carpal tunnel release: clinical, electrodiagnostic, and ultrasound features in 12 patients. Patient series

BACKGROUND

Nerve injuries during carpal tunnel release (CTR) are rare. Electrodiagnostic (EDX) and ultrasound (US) studies may be helpful in evaluating iatrogenic nerve injuries during CTR.

OBSERVATIONS

Nine patients sustained a median nerve injury, and 3 patients experienced ulnar nerve damage. Decreased sensation occurred in 11 patients, and dysesthesia occurred in 1 patient. Abductor pollicis brevis (APB) weakness occurred in all patients with median nerve injury. Of the 9 patients with median nerve injury, the compound muscle action potentials (CMAPs) of the APB and sensory nerve action potentials (SNAPs) of the 2nd or 3rd digit were not recordable in 6 and 5 patients, respectively. Of the 3 patients sustaining ulnar nerve injuries, the CMAPs of the abductor digiti minimi (ADM) and SNAPs of the 5th digit were not recordable in 1 patient; 2 patients showed prolonged latency and decreased amplitude of CMAPs/SNAPs. US studies of 8 patients with a median nerve injury showed a neuroma within the carpal tunnel. One patient underwent surgical repair urgently, and 6 did so after variable intervals.

LESSONS

Surgeons should be cognizant of nerve injuries during CTR. EDX and US studies are useful in evaluating iatrogenic nerve injuries during CTR.

A Nationally Validated Novel Risk Assessment Calculator for Prediction of Unplanned Reoperations and Readmissions in Hand Surgery

BACKGROUND

Risk predictors are an emerging tool as the need for individualized risk estimation in clinical decision-making persists. Existing risk indices have had limited success in accurately predicting hand surgery risks. This study provides a novel risk calculator for reliably predicting reoperations and readmissions in hand surgery.

METHODS

Hand surgeries from the National Surgical Quality Improvement Program (NSQIP) 2012-2019 database were identified. Independent predictors of 30-day unplanned reoperation and readmission were identified in the modeling sample (2012-2019) and subsequently weighted to generate a Novel Risk Score (NRS). The NRS was validated on a 2020 NSQIP hand surgery cohort and compared to the modified frailty index (mFI-5) and the modified Charlson Comorbidity Index (mCCI) with receiver operating characteristics (ROC) analysis.

RESULTS

Eighty-three thousand four hundred nine hand surgeries were identified for modeling. Reoperations and readmissions rates were 1.1% and 1.3%, respectively. Independent risk factors included male gender, inpatient status, smoking, dialysis dependence, transfusion within 72 h of surgery, wound classification, ASA class, diabetes mellitus, CHF, sepsis or septic shock, emergent case, and operative time longer than 75 min (all P < 0.05). ROC analysis of the 2020 cohort rendered an area under the curve (AUC) of 0.730, which demonstrates the accuracy of this prediction model. The mFI-5 and mCCI rendered AUCs of 0.580 and 0.585, respectively.

CONCLUSION

We present a validated risk prediction tool for unplanned reoperations and readmissions following hand surgery that outperforms the mFI-5 and mCCI that are available online. Future studies should evaluate clinical efficacy.

A five-year retrospective cohort study of carpal tunnel surgery complications in an Australian population

BACKGROUND

Carpal tunnel syndrome is a common compressive neuropathy. There is a lack of comprehensive studies evaluating carpal tunnel release (CTR) complications in Australia. This study aimed to evaluate complication rates associated with open and endoscopic CTR in an Australian population, and to identify associated risk factors.

METHODS

Retrospective cohort study of 1287 CTR from 2015 to 2020. Methods of release were endoscopic, open and surgery concomitant with synovectomy or other. Outcomes included wound infection, dehiscence, nerve injury, complex regional pain syndrome, incomplete release, and re-operation. Statistical analysis included Chi-squared test, Fisher's exact test, Odds ratio and logistic regression.

RESULTS

There were 71 total complications (5.5%), including 35 Clavien-Dindo IIIb complications. There was no difference in complication rates for endoscopic (3.3%) versus open (8.3%) CTR (P = 0.18). The overall rate of complications was higher in CTR with concomitant surgery (8.5%) compared to CTR alone (5.2%), though this was not statistically significant (P = 0.058). There was no association between rates of complications and immune suppression (p = 0.55), rheumatoid disease (P = 0.61), or smoking status (P = 0.72). Diabetes mellitus was associated with an increased risk of Clavien-Dindo IIIb complications (P = 0.028, OR 2.15, 95% CI 1.07-4.32). There was no association between surgical experience and complication rate (P = 0.55).

CONCLUSION

Open and endoscopic CTR surgeries have similar rates of complications. Diabetes is associated with higher rates of Clavien-Dindo IIIb complications. Identification of high-risk patients allows for the application of risk-mitigation strategies in the perioperative setting.

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.

[Differential therapeutic Approaches in Treatment of Carpal Tunnel Syndrome]

Carpal tunnel syndrome (CTS) is one of the most common compression neuropathies. The therapeutic concept should be tailored to each patient individually, with initial non-surgical treatment being the standard of care for early CTS. Primary surgical intervention should be considered in more advanced diseases stages, in case of concomitant pathologies (including space-occupying lesions, complex regional pain syndrome or diabetic neuropathy), if non-surgical strategies have failed or in pregnancy-related CTS. This work aims to discuss common surgical approaches, their clinical application as well as benefits and disadvantages in a pragmatic style. Further, we highlight surgical strategies to address recurrent CTS following failed primary surgery. In view of the recently updated S3 guidelines "Diagnosis and Therapy of Carpal Tunnel Syndrome", this topic is timely and relevant for hand and nerve surgeons.

Developing Machine Learning Algorithms to Support Patient-centered, Value-based Carpal Tunnel Decompression Surgery

Background:

Methods:

Results:

Conclusions:

A Systematic Review of Randomised Control Trials Evaluating the Efficacy and Safety of Open and Endoscopic Carpal Tunnel Release

INTRODUCTION

Carpal tunnel syndrome is the most prevalent form of nerve compression syndrome of the upper limb; therefore, it is of clinical significance to critique treatment methods. There is an ongoing debate amongst clinicians as to which surgical method-open or endoscopic carpal tunnel release-provides better overall symptom relief and faster recovery time. This systematic review aimed to investigate the evidence from randomised control trials to evaluate the effectiveness and safety of open and endoscopic carpal tunnel release surgery.

METHODS

Database searches were carried out to identify literature. An inclusion and exclusion criteria was applied to only include randomised control trials which compared open and endoscopic surgery. Publications were then selected according to PRISMA guidelines, risk of bias was assessed and patient outcome was assessed.

RESULTS

Twenty-three studies were selected for this systematic review. It was found that for improvement to grip strength and symptom severity, the endoscopic group had more significant improvement in the short term, resulting in a quicker return to work time compared to the open group. The complication rate for both intervention groups was low despite more severe and irreversible complications such as prolonged pain and wound infections being observed in the open group; however, the endoscopic group reported a higher risk of needing repeat surgery.

CONCLUSION

The quicker recovery time, improved cosmetic result and less severe complications observed with the endoscopic technique suggest that it should be used more often. However, this review found no convincing evidence of a significantly superior technique in the long term.

Perioperative Complications and Adverse Events after Surgery for Peripheral Nerve- and Para-lumbar Spine Diseases

Peripheral nerve diseases are common. Para-lumbar spine diseases (PLSDs) include peripheral neuropathy around the lumbar spine, e.g., cluneal nerve entrapment and gluteus medius muscle pain. While these diseases can be treated by less invasive surgery, postoperative complications have not been sufficiently investigated. We document complications after surgery for peripheral nerve diseases and PLSDs. Between July 2014 and December 2020, 678 consecutive patients with peripheral nerve diseases and PLSDs underwent 1068 surgical procedures (upper limb 200 sites, lower limb 447 sites, para-lumbar spine 394 sites, and tumor 27 sites). After excluding 27 procedures to address tumors, we examined the remaining 1,041 procedures undergone by 672 patients (average age 68.2 years) and recorded the complication rate observed within 30 days after the procedures. The overall surgical complication rate was 3.9% (41/1041 procedures); 6 procedures required surgical salvage and 35 were treated conservatively. There were no long-term sequelae from complications. The complication rate was high after surgery for lateral femoral cutaneous-, saphenous-, and common peroneal nerve entrapment and tarsal tunnel syndrome; all sites involved the lower limbs. As a result, intergroup comparison showed that the complication rate was significantly higher for the upper limb (3.0%) procedures than the lower limb (6.7%) and PLSD (1.3%) procedures. It was significantly lower for PLSD operations than lower and upper limb operations. The patient age and diabetes mellitus were significant risk factors for postoperative complications. Their rate was low in patients treated for peripheral nerve diseases and PLSDs; 34 of the 41 complications (82.9%) were related to the surgical wound.