Predictors of the patient-centered outcomes of surgical carpal tunnel release - a prospective cohort study

Does Revision Carpal Tunnel Release Result in Long-Term Outcomes Equivalent to Single Carpal Tunnel Release? A Matched Case-Control Analysis

BACKGROUND

The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR.

METHODS

The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire.

RESULTS

A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery.

CONCLUSION

Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.

Association Between Pain Coping and Symptoms of Anxiety and Depression, and Work Absenteeism in People With Upper Limb Musculoskeletal Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To determine the prospective association of pain coping strategies and symptoms of anxiety and depression with work absenteeism in people with upper limb musculoskeletal disorders.

DATA SOURCES

A systematic search of PubMed, Web of Science, Embase, Cochrane Library, and Scopus databases was conducted from inception to September 23, 2022.

STUDY SELECTION

Prospective observational studies of adults with upper limb musculoskeletal disorders were included. Included studies had to provide data on the association of pain coping strategies (catastrophizing, kinesiophobia, self-efficacy or fear avoidance) or symptoms of anxiety and depression with work absenteeism.

DATA EXTRACTION

Study selection, data extraction, and assessment of methodological quality (Newcastle Ottawa Scale) were performed by 2 independent authors. Random-effects models were used for quantitative synthesis.

DATA SYNTHESIS

Eighteen studies (n=12,393 participants) were included. Most studies (77.8%) reported at least 1 significant association between 1 or more exposure factors (pain coping strategies or symptoms of anxiety and depression) and work absenteeism. Meta-analyses showed a statistically significant correlation between the exposure factors of catastrophizing (r=0.28, 95% confidence interval [CI]: 0.15 to 0.40; P<.0001) and symptoms of anxiety and depression (r=0.23, 95% CI: 0.10 to 0.34; P=.0003) with work absenteeism. The correlation between self-efficacy and work absenteeism was non-significant (r=0.24, 95% CI: -0.02 to 0.47; P=.0747).

CONCLUSIONS

Rehabilitation teams should consider assessing catastrophizing and symptoms of anxiety and depression to identify patients at risk for work absenteeism. Addressing these variables may also be considered in return-to-work programs for individuals with upper limb disorders.

A Logistic Regression Analysis of Factors Associated with Guarded Outcome after Carpal Tunnel Release in Symptomatic Carpal Tunnel Syndrome

BACKGROUND

The Boston Carpal Tunnel Questionnaire (BCTQ) is a validated measurement tool to assess the severity of carpal tunnel syndrome, and improvements in the BCTQ after carpal tunnel release (CTR) have been demonstrated to influence patient satisfaction. The authors hypothesized that patient-related factors influence response in BCTQ subscales, including the Symptom Severity Scale and the Functional Status Scale, after CTR.

METHODS

Patients who underwent surgery with follow-up BCTQ were identified from a prospectively maintained database. Paired t tests were used to compare BCTQ subscales at each follow-up time point. Minimal clinically important differences were set. Patients below these thresholds were deemed as having failure to improve after CTR. Univariate analysis was used to identify risk factors for failure to improve after CTR. Multivariate logistic regression was used to identify independent predictors for failure to improve after CTR.

RESULTS

A total of 106 patients met inclusion criteria. Patients demonstrated significant improvements at all follow-up time points. The factor most associated with improvement beyond the minimal clinically important differences was a more severe score in the respective domain assessed. Other independent factors that influenced outcome after CTR included race, concomitant cubital tunnel release, sex, and age.

CONCLUSIONS

CTR results in significant improvements in BCTQ and its subscales, with improvements stabilizing after 6 weeks. In a select cohort of patients, failure to improve after CTR occurs with factors independently associated with a lower degree of improvement. Identification of patients with these risk factors will provide a basis for counseling and increased monitoring of patients at risk for a guarded prognosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Is the outcome of a revision carpal tunnel release as good as those of a primary release? A matched cohort study

OBJECTIVE

This study aimed to compare primary and revision carpal tunnel release outcomes in all patients with carpal tunnel syndrome and when corrected for baseline severity and demographics.

METHODS

A total of 903 hands of primary and 132 hands of revision patients underwent carpal tunnel release and patients completed online questionnaires on demographics, clinical severity, and satisfaction. The primary outcome measure, the Boston Carpal Tunnel Questionnaire (BCTQ), was administered at intake and six months after surgery.

RESULTS

The BCTQ total score at six months was better in primary (1.55±0.58) than revision patients (1.94±0.73, p=<0.001), and primary patients improved more on the BCTQ total score (1.10±0.71 vs. 0.90±0.72, p=0.003). In patients matched on similar baseline characteristics using propensity score matching, the BCTQ total score at six months was also better in primary patients (1.65±0.63) than in revision patients (1.92±0.73, p=0.002), and primary patients still had more improvement in BCTQ total score (1.18±0.73 vs. 0.89±0.73, p=0.004).

CONCLUSIONS

This study shows that the outcome after revision carpal tunnel release is only 16% worse compared to primary carpal tunnel release. Preoperative symptom severity, functional status, and demographics may play a role since correcting for these factors reduces the difference in outcome between primary and revision CTR.

The Utility of the Carpal Tunnel Syndrome-6 for Predicting the Outcomes of Carpal Tunnel Release

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

A Systematic Review of the Outcomes of Carpal Ligament Release in Severe Carpal Tunnel Syndrome

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Relationship between clinical outcomes and nerve conduction studies before and after surgery in patients with carpal tunnel syndrome

Background

Nerve conduction study (NCS) is the only useful test for objective assessment of carpal tunnel syndrome (CTS). However, the relationship between pre- and postoperative NCS and clinical outcomes was unclear. This study aimed to determine whether pre- and postoperative (6 months) NCS could predict patient-oriented and motor outcomes (6 and 12 months postoperatively) in patients with CTS.

Method

Of the 85 patients with CTS, 107 hands were analyzed from March 2011 to March 2020. All patients underwent open carpal tunnel release and were examined using the disabilities of the arm, shoulder and hand (DASH) questionnaire and grip strength (GS) preoperatively and 6 and 12 months postoperatively. Moreover, NCS was examined preoperatively and 6 months postoperatively. Distal motor latency (DML) and sensory conduction velocity (SCV) were the parameters used for NCS. The correlation coefficient between NCS and DASH or GS was calculated. A receiver operating characteristic curve was utilized to determine the NCS threshold value to predict DASH and GS improvement.

Results

The average scores of GS preoperatively and 6 and 12 months postoperatively were 21.3, 22.3, and 22.8, respectively. On the other hand, the average scores of DASH preoperatively and 6 and 12 months postoperatively were 28.8, 18.3, and 12.2, respectively. The average NCS scores (DML and SCV) preoperatively/6 months postoperatively were 7.3/5.4 and 27.8/36.7, respectively. Preoperative NCS did not correlate with DASH and GS. Postoperative SCV correlated with the change in grip strength (6–12 months, r = 0.67; 0–12 months, r = 0.60) and DASH (0–12 months, r = 0.77). Moreover, postoperative DML correlated with the change in DASH (6–12 months, r = − 0.33; 0–12 months, r = − 0.59). The prediction for the improvement of GS/DASH achieved a sensitivity of 50.0%/66.7% and a specificity of 100%/100%, at an SCV cutoff score of 38.5/45.0 or above. The prediction for improvement of GS/DASH achieved a sensitivity of 83.3%/66.7% and a specificity of 100%/66.7% at a DML cutoff score of 4.4/4.4 or below.

Conclusion

NCS at 6 months postoperatively can be used to predict the improvement of clinical outcome after 6 months postoperatively in patients with CTS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04771-y.

Patient Mindset and the Success of Carpal Tunnel Release

BACKGROUND

Depression and pain catastrophizing are aspects of the patient's mindset that have been shown to be important in relation to the outcome of carpal tunnel release. However, other factors of the patient's mindset have been understudied, such as treatment expectations and illness perceptions. The aim of the present study was to investigate the influence of these mindset aspects on outcome of carpal tunnel release, in addition to psychological distress and pain catastrophizing.

METHODS

A total of 307 patients with carpal tunnel syndrome who visited outpatient hand surgery clinics and who completed online questionnaires regarding demographic and psychosocial characteristics and carpal tunnel syndrome severity were included. The patient mindset was measured with the Patient Health Questionnaire-4, the Pain Catastrophizing Scale, the Credibility Expectancy Questionnaire, and the Brief Illness Perception Questionnaire. Hierarchical linear regression models were used to examine the relation between self-reported severity 6 months after carpal tunnel release, as measured with the Boston Carpal Tunnel Questionnaire, and psychosocial aspects of mindset, adjusting for preoperative Boston Carpal Tunnel Questionnaire score, patient characteristics, and comorbidities.

RESULTS

Independent associations with better self-reported outcome were found for higher treatment expectations (β = -0.202; p < 0.001) and illness comprehensibility (β = -0.223; p < 0.001). The additional explained variance in Boston Carpal Tunnel Questionnaire scores by the patient's mindset was 13.2 percent (psychological distress and pain catastrophizing together, 2.1 percent; treatment expectations and illness perceptions together, 11.1 percent).

CONCLUSION

Treatment outcome expectations and comprehensibility of illness are both independently associated with the outcome of carpal tunnel release, showing the importance of these aspects of the patient's mindset for the outcome of carpal tunnel release.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Clinical predictors of surgical outcomes of severe carpal tunnel syndrome patients: utility of palmar stimulation in a nerve conduction study

Background

Carpal tunnel syndrome is a common peripheral nerve compression disorder. However, there is no established opinion regarding the predictors of symptom improvement after surgery. This study aimed to identify the predictors of surgical outcomes of severe carpal tunnel syndrome patients.

Methods

In the patients who underwent a carpal tunnel syndrome surgery, we selected the patients who had a preoperative Bland’s classification of grade 5 or 6, and assessed for the changes in Bland’s classification grade before and after surgery. Those who showed improvement from preoperative grades 5–6 to postoperative grades 1–4 comprised the improvement group. In contrast, those who did not show improvement and had postoperative grades 5 or 6 comprised the non-improvement group. In a nerve conduction study, amplitudes of the compound muscle action potential and sensory nerve action potential of the palms were assessed between the improvement and non-improvement groups.

Results

Among the 60 hands of 46 patients who had a preoperative Bland’s classification of grade 5 or 6, 49 hands of 37 patients comprised the improvement group, and 11 hands of 9 patients comprised the non-improvement group. The amplitudes of the compound muscle action potential and sensory nerve action potential of the palms before surgery were significantly higher in the improvement group. The degree of improvement in Bland’s classification grade was correlated with the degree of clinical symptom improvement.

Conclusions

Amplitudes of compound muscle action potential and sensory nerve action potential before surgery induced by palmar stimulation can predict improvements in nerve conduction study scores and clinical findings after surgical treatment.

Risk factors for limited improvement after total trapeziometacarpal joint arthroplasty

Background

Trapeziometacarpal (TMC) osteoarthritis can be painful and cause disability for patients. Total joint replacement of the TMC joint provides a pseudo arthrosis with good restoration of the thumb motion and pain relief in most patients. But there is also a risk of no improvement following the operation. The purpose of this study was to identify patients at risk of no clinically important improvement following operative treatment of osteoarthritis of the TMC joint.

Methods

We included 287 consecutive patients (225 women, 62 men) treated with total joint replacement of the TMC joint due to osteoarthritis with a mean age of 58.9 years (range 41–80) in a prospective cohort study. We collected information preoperatively and 12 months postoperatively on disabilities of the arm, shoulder and hand score (DASH), grip strength and pain at rest and activity on a visual analogue scale (VAS).Results: We found a statistically significant improvement in DASH from 42.0 to 15.9 (p < 0.001), VAS at rest from 3.5 to 0.6 (p < 0.001), VAS at activity from 7.9 to 2.5 (p < 0.001) and grip strength from 21.6 kg to 27.6 kg (p < 0.001) 12 months after the operation, when analysed as a group. There was an increased risk of no clinically important improvement in hand function for patients with preoperative high preoperative grip strength. Also, we found an increased risk of no clinically important improvement in female patients when using VAS as outcome.

Conclusion

However, we were unable to detect one isolated preoperative predictor as indicator of successful result after operative treatment of TMC osteoarthritis, and as so it was not possible to establish a clinical valid tool for patient selection before surgery.

Informed consent was obtained from all patients for being included in the study. The study needed no approval from The Regional Committee of Biomedical Research Ethics as the data was collected, as part of our normal pre- and postoperative clinical pathway, but the study is part of an outcome study of the results after total joint arthroplasty (TJA) of the TMC joint registered in Clinicaltrials.gov (NCT01554748).

Trial registration

Clinicaltrials.gov (NCT01554748). Registered 15 March 2012.

Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study

Background

Carpal tunnel syndrome is a common upper-limb nerve compression disease. Carpal tunnel syndrome can lead to several symptoms such as tingling or numbness, pain in the hand or wrist, and reduced grip strength. Based on demographic characteristics, patient reported outcome measures, and with special attention to pain catastrophizing, the purpose of this study was to identify risk factors for low patient-reported satisfaction following surgical treatment of idiopathic carpal tunnel syndrome.

Methods

A total of 417 hands from 417 patients (64. 5% females) with a mean age of 58. 0 years were included in this 1-year prospective follow-up study. We collected preoperative data on disability using the Disability of the Arm, Shoulder and Hand questionnaire (DASH), quality of life using the EuroQol-5D (EQ-5D), pain catastrophizing using the Pain Catastrophizing Scale (PCS) and distal motor latency. Data on DASH score, EQ-5D, and patient satisfaction was collected 12 months postoperatively. Wilcoxon matched-pairs signed-rank test was used to test for difference in preoperative and postoperative DASH and EQ-5D score. Risk factors for low postoperative patient reported satisfaction was examined using stepwise multiple logistic regression analysis.

Results

We found a general improvement in patients’ DASH scores (12.29 [95% CI: 10.65–13.90], p < 0.001) and EQ-5D (0.14 [95% CI: 0.13–0.16], p < 0.001) from preoperative to 12 months postoperative. In the fully adjusted multiple regression analysis we found a statistically significant effect of preoperative PCS on patient reported satisfaction with OR = 1.05 (p = 0.022), for a one unit increase in preoperative PCS. There was no statistically significant predictive effect of preoperative EQ-5D (p = 0.869), DASH (p = 0.076), distal motor latency (p = 0.067), age (p = 0.505) or gender (p = 0.222).

Conclusions

Patients improved in both DASH and EQ-5D from preoperative to 12 months postoperative. Higher preoperative PCS seems to have a negative effect on postoperative patient reported satisfaction after carpal tunnel release.

Outcome after carpal tunnel release: effects of learning curve

INTRODUCTION

In carpal tunnel release, it is yet unclear whether a learning curve exists among surgeons. The aim of our study was to investigate if outcome after carpal tunnel release is dependent on surgeon's experience and to get an impression of the learning curve for this procedure.

METHODS

A total of 188 CTS patients underwent carpal tunnel release. Patients completed the Boston Carpal Tunnel Questionnaire at baseline and 6-8 months postoperatively together with a six-point scale for perceived improvement.

RESULTS

Patients operated by an experienced resident or certified surgeon reported a favorable outcome more often than patients operated by an inexperienced resident (adjusted OR 3.23 and adjusted OR 3.16, respectively). In addition, a negative association was found between surgeon's years of experience and postoperative Symptom Severity Scale and Functional Status Scale scores.

DISCUSSION

Outcome after carpal tunnel release seems to be dependent on surgical experience, and there is a learning curve in residents.

Long-term outcome after carpal tunnel release and identification of prognostic factors

BACKGROUND

The effectiveness of the surgical treatment of carpal tunnel syndrome (CTS) is well known on short term. However, limited data is available about long-term outcome after carpal tunnel release (CTR). The aims of this study were to explore the long-term outcome after CTR and to identify prognostic factors for long-term outcome.

METHODS

Patients with clinically defined CTS underwent CTR and completed the Boston Carpal Tunnel Questionnaire at baseline (T₀), at about 8 months (T₁), and after a median follow-up of 9 years (T₂), as well as a 6-point scale for perceived improvement (at T₁ and T₂). Potentially prognostic factors were identified by logistic regression analysis and correlation.

RESULTS

At long-term follow-up, 87 patients (40.3%) completed the questionnaires. Mean score on Symptom Severity Scale (2.87 to 1.54; p < 0.001) and Functional Status Scale (2.14 to 1.51; p < 0.001) improved at 8 months and did not change significantly after 8 months. A favorable outcome was reported in 81.6%. A good treatment outcome after 8 months and to a lesser extent a lower FSS score at T₀ were associated with a better long-term outcome.

CONCLUSIONS

CTR is a robust treatment for CTS and its effect persists after a period of 9 years. The most important factor associated with long-term outcome is treatment outcome after about 8 months and to a lesser extent functional complaints preoperatively. Outcome is independent of patient characteristics, electrodiagnostic test results, or findings at the initial neurological examination.

Minimal clinically important difference for the Boston Carpal Tunnel Questionnaire: new insights and review of literature

No consensus exists about the minimal clinically important difference for the Boston Carpal Tunnel Questionnaire, which hampers its clinical application. This study assessed the minimal clinically important difference of this questionnaire. The Boston Carpal Tunnel Questionnaire was completed by 180 patients, with clinically defined carpal tunnel syndrome, preoperatively and at about 8 months follow-up after carpal tunnel release, together with a six-point scale for perceived improvement. Receiver operator characteristics curves showed that relative changes in Symptom Severity Scale and Functional Status Scale scores correspond better to a clinically relevant improvement than absolute changes. The minimal clinically important difference should be individually calculated from baseline Symptom Severity Scale and Functional Status Scale scores, as patients experiencing more symptoms require more improvement to notice a clinically important difference. By taking this into account, the Boston Carpal Tunnel Questionnaire is more meaningful as an outcome measure in research and clinical practice.

The Net Promoter Scores with Friends and Family Test after four hand surgery procedures

The Friends and Family Test, a variant of the Net Promoter Score, was adapted for the National Health Service to evaluate overall patient satisfaction and how likely patients are to recommend an intervention. It ranges from -100 to 100. Positive scores indicate good performance. This study quantifies the scores in 810 patients at a mean of 14 months following four common procedures. The score was 83 for trigger finger release ( n = 103), 68 for carpal tunnel decompression ( n = 467), 62 for surgery for Dupuytren's disease ( n = 224) and 44 for ganglia excision ( n = 16). Our study indicates that these procedures are highly valued and are recommended by patients according to the Friends and Family Test. The results of the Friends and Family Test correlated well with postoperative functional improvement and satisfaction. We conclude from this study that a compound score based on the Friends and Family Test is a useful addition to traditional measures of patient satisfaction. Level of evidence: II.

Thumb Opposition Recovery Following Surgery for Severe Carpal Tunnel Syndrome: A Clinical, Radiological, and Electrophysiological Pilot Study

PURPOSE

To objectively assess recovery of thumb opposition in patients with carpal tunnel syndrome (CTS) after open carpal tunnel release and to evaluate electrophysiological and magnetic resonance (MR) neurography findings as predictors of thumb opposition recovery.

METHODS

A total of 22 patients with severe CTS and thenar atrophy were included in this study. A detailed clinical, electrophysiological, and MR neurography evaluation was done both before and after surgery at 6 months to assess thumb opposition recovery.

RESULTS

The median duration of symptoms was 12 months (interquartile range, 12-20 months). The compound muscle action potential of the abductor pollisis brevis (CMAP-APB) also showed statistically significant improvement of 0.5 + 0.2 mV after surgery. Tip-tip pulp pinch strength increased from 1.2 ± 0.4 to 2.0 ± 0.4 kg at 6-month follow-up, lateral pulp pinch strength increased from 1.9 ± 0.6 to 2.8 ± 0.9 kg at 6-month follow-up, and 3-point pulp pinch also improved from 1.9 ± 0.5 to 2.8 ± 0.9 at final follow-up. On MR neurogram, the proportion of patients with abnormal median nerve morphology decreased from 81.8% to 68.2%, abnormal thenar branch morphology decreased from 63.6% to 36.4% and denervation edema deceased from 59.1% to 13.6%.

CONCLUSIONS

Patients suffering from severe CTS with thenar atrophy and detectable CMAP-APB showed promising improvement following open carpal tunnel release.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Does the Duration and Severity of Symptoms Have an Impact on Relief of Symptoms after Carpal Tunnel Release?

Rationale  Carpal tunnel syndrome (CTS) is the most frequently encountered compressive neuropathy of the upper limb. The treatment of CTS ranges from conservative management to carpal tunnel release. Many patients with misconception about the potential morbidity and with the hope of successful conservative treatment delay the surgical release of carpal tunnel. This delay results in reduced recovery of sensory and motor median nerve function. Objective  The aim of this study was to evaluate the influence of preoperative duration and severity of symptom on the outcome of carpal tunnel surgery. Method  It included 45 cases of CTS, all treated with limited access open carpal tunnel release. The duration of symptoms (i.e., pain, numbness, tingling, waking up at night because of pain/numbness, difficulty in grasping small objects, and their preoperative severity) was noted using Boston CTS questionnaire. To investigate the outcome, patients were divided into three groups based on their duration of symptoms. Result  Group1: The severity of symptoms was reduced to normal in a short period of time in patients who presented with duration of symptoms less than 6 months. Group 2: Patients in whom symptoms lasted for 6 to 12 months had reduced or delayed recovery of hand function as compared with first group. Group 3: Patients who had symptoms for more than 12 months had incomplete recovery of grip strength. Return to normal function took the longest time (median: 16 weeks) in this group. Conclusion  This study suggests that patients who present late have delayed/incomplete relief of symptoms after carpal tunnel release.

Predicting Clinical Outcome After Surgical Treatment in Patients With Carpal Tunnel Syndrome

PURPOSE

Carpal tunnel release (CTR) is typically offered to symptomatic patients with electrophysiological abnormalities when night orthoses no longer prevent waking with numbness and preferably before there is any static numbness, weakness, or atrophy. The ability to predict the amount of symptom relief after CTR could be beneficial for managing patient expectations and, therefore, improve treatment satisfaction. Therefore, the aim of this study was to identify predictors for symptom relief after CTR and to determine their contribution to symptom relief at 6 months after surgery.

METHODS

A total of 1,049 patients who underwent CTR between 2011 and 2015 at 1 of 11 Xpert Clinics in the Netherlands were asked to complete online questionnaires at intake and 3 and 6 months after surgery. Patient demographics, comorbidities, and baseline scores were considered potential predictors for the amount of symptom relief on the Boston Carpal Tunnel Questionnaire (BCTQ) score, which was the primary outcome measure.

RESULTS

A low score on the BCTQ at intake, a codiagnosis of a trigger finger, ulnar nerve neuropathy, trapeziometacarpal joint arthrosis, and instability or arthrosis of the wrist were associated with a smaller improvement in the BCTQ domains after a CTR at 6 months after surgery and accounted for 35% to 42% of the variance on the BCTQ domains in our multivariable regression models.

CONCLUSIONS

In this study, we showed that clinical severity of carpal tunnel syndrome at intake is the most important factor in estimating symptom relief after surgical treatment. Furthermore, this study contributes to a more precise understanding of the capabilities of CTR in relieving symptoms for different subgroups of patients. Results of our study can be used to manage patient expectation on symptom relief from CTR.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Hand Surgeons Performing More Open Carpal Tunnel Releases Do Not Show Better Patient Outcomes

BACKGROUND

Although previous studies have shown that more experienced surgeons have better patient outcomes following a variety of procedures, in hand surgery and carpal tunnel release in particular, this relation remains unproven. The authors assessed whether there is an association between surgeon volume and patient outcomes following open carpal tunnel release.

METHODS

Patients who underwent carpal tunnel release between 2011 and 2015 at outpatient hand surgery clinics in The Netherlands were included. Surgeon annual volume was defined as the average number of carpal tunnel releases performed per year per participating surgeon over the study period. Primary outcome measures were the Symptom Severity Scale and Functional Status Scale of the Boston Carpal Tunnel Questionnaire 6 months postoperatively. Multilevel random intercept linear regression analyses were performed to assess whether there was an association between surgeon annual volume and outcome measures, with adjustment for patient characteristics, concomitant procedures, and intake score on the Boston Carpal Tunnel Questionnaire.

RESULTS

A total of 1345 patients were included, operated on by 17 surgeons. Median annual surgeon volume was 75 (interquartile range, 50 to 149). Only 0.5 to 0.6 percent of the total variance in patient outcome on the Boston Carpal Tunnel Questionnaire could be explained by random differences between surgeons. The authors did not find an association between annual surgeon volume and outcome measures 6 months postoperatively (Symptom Severity Scale: β = 0.000; 95 percent CI, -0.001 to 0.001; and Functional Status Scale: β = 0.000; 95 percent CI, -0.001 to 0.001).

CONCLUSION

In the authors' sample of highly specialized hand surgeons operating in high-volume centers, they found no differences in outcome between high- and low-volume surgeons.

Preoperative predictors of patient satisfaction after carpal tunnel release

BACKGROUND

We investigated preoperative factors among demographic and clinical characteristics, as well as psychological factors that influence postoperative patient satisfaction, with the goal of assisting preoperative patient consultation for CTR.

MATERIALS AND METHODS

We included 92 hands from 60 patients diagnosed with idiopathic carpal tunnel syndrome. We selected the following factors as possible preoperative predictors for patient satisfaction: age, sex, duration of symptoms, static two-point discrimination, the Semmes-Weinstein monofilament test, grip strength, electrophysiological category and scores for the Boston Carpal Tunnel Questionnaire, the Pain Anxiety Symptoms scale and the Center for the Epidemiological Study of Depression scale. We used a cumulative logit model with generalized estimation equations to identify the predictors of patient satisfaction after CTR.

RESULTS

Univariate analyses demonstrated significant correlations of patient satisfaction with age, preoperative grip power and preoperative CES-D. Multivariate analyses showed that age and preoperative CES-D scores were significantly correlated with patient satisfaction.

CONCLUSION

Age and depression level were preoperative predictors influencing satisfaction after CTR.

LEVELS OF EVIDENCE

IV.

Thromboprophylaxis for ambulatory surgery: Results from a prospective national cohort

BACKGROUND

Venous thromboembolism (VTE) prophylaxis is not always part of the usual care of ambulatory surgery patients, and few guidelines are available.

OBJECTIVES

To collect data on the application of VTE prophylaxis in ambulatory patients.

DESIGN

The OPERA study is a large national survey performed in 221 healthcare facilities.

PATIENTS

Among patients, 2174 who underwent one of ten selected procedures over two pre-defined days of investigation.

MAIN OUTCOME MEASURES

Assessment and management of the postoperative VTE risk.

RESULTS

The postoperative VTE risk was assessed as nil (4.1% of the physicians), low (74%) or moderate (20%). This risk was assessed as lower (71%) in ambulatory surgery as compared to conventional surgery. In most centres (94%), a personal patient history of VTE was recorded preoperatively, and in 72% a prophylaxis protocol was systematically applied but only 40% of the responding centres had a written protocol for VTE prophylaxis. The postoperative period (discharge at home) was covered by a VTE protocol for 75% of the centres, with VTE prophylaxis starting postoperatively in 21% of the patients. In these patients, different treatments were applied: below-knee compression stockings (25%); thigh-length compression stockings (21%); intermittent pneumatic compression in the recovery room (1.2%); unfractionated heparin (2.0%); low molecular weight heparins (65%); vitamin K antagonists (0.5%); other treatments, including direct oral anticoagulants (0.5%).

CONCLUSION

These data underline the need for a better assessment of the VTE risk in ambulatory patients and new studies either with conventional or new agents to be able to build guidelines in this new setting.

Quality of care and patient-reported outcomes in carpal tunnel syndrome: A prospective observational study

INTRODUCTION

Higher quality care for carpal tunnel syndrome (CTS) may be associated with better outcomes.

METHODS

This prospective observational study recruited adults diagnosed with CTS from 30 occupational health centers, evaluated physicians' adherence to recommended care processes, and assessed results of the Boston Carpal Tunnel Questionnaire (BCTQ) and Short Form Health Survey version 2 (SF-12v2) at recruitment and at 18 months.

RESULTS

Among 343 individuals, receiving better care (80th vs. 20th percentile for adherence) was associated with greater improvements in BCTQ Symptom Severity scores (-0.18, 95% confidence interval [CI] -0.32 to -0.05), BCTQ Functional Status scores (-0.21, 95% CI -0.34 to -0.08), and SF12-v2 Physical Component scores (1.75, 95% CI 0.33-3.16). Symptoms improved more when physicians assessed and managed activity, patients underwent necessary surgery, and employers adjusted job tasks.

DISCUSSION

Efforts should be made to ensure that patients with CTS receive essential care processes including necessary surgery and activity assessment and management. Muscle Nerve 57: 896-904, 2018.

Geriatric Cyclists: Assessing Risks, Safety, and Benefits

Nearly 1 in every 3 Americans ride bicycles each year, but only 20% of the reported 100 million cyclists ride on a weekly basis. Bicycling is a common form of transportation and recreation and has gained popularity among the elderly patients. In recent years, the number of elderly cyclists has increased steadily and studies have cited ease of use, need for exercise, and enjoyment as important contributing factors. The benefits of physical activity on health is well-documented, and elderly individuals are encouraged to remain active to reduce the progression of age-related weakness and loss of muscle mass. Safety concerns, however, have been a prevalent public health issue. According to the Center for Disease Control and Prevention, elderly and teenage cyclists account for the highest number of head injuries and fatalities among all cyclists. Safety measures that include wearing protective gear such as helmets and choosing the appropriate bicycle have been recommended to minimize the risk of sustaining injuries while riding. Despite these concerns, bicycling has remained a popular and exciting activity for the elderly patients.

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 6 months. A significant improvement of complaints was reported by 70.0% of the surgically treated patients and 39.4% reported full recovery 6 months 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.