The influence of age on outcome after operation for the carpal tunnel syndrome

Rejuvenating fecal microbiota transplant enhances peripheral nerve repair in aged mice by modulating endoneurial inflammation

Peripheral nerve injury (PNI) resulting from trauma or neuropathies can cause significant disability, and its prognosis deteriorates with age. Emerging evidence suggests that gut dysbiosis and reduced fecal short-chain fatty acids (SCFAs) contribute to an age-related systemic hyperinflammation (inflammaging), which hinders nerve recovery after injury. This study thus aimed to evaluate the pro-regenerative effects of a rejuvenating fecal microbiota transplant (FMT) in a preclinical PNI model using aged mice. Aged C57BL/6 mice underwent bilateral crush injuries to their sciatic nerves. Subsequently, they either received FMT from young donors at three and four days after the injury or retained their aged gut microbiota. We analyzed gut microbiome composition and SCFA concentrations in fecal samples. The integrity of the ileac mucosal barrier was assessed by immunofluorescence staining of Claudin-1. Flow cytometry was utilized to examine immune cells and cytokine production in the ileum, spleen, and sciatic nerve. Various assessments, including behavioural tests, electrophysiological studies, and morphometrical analyses, were conducted to evaluate peripheral nerve function and repair following injury. Rejuvenating FMT reversed age-related gut dysbiosis by increasing Actinobacteria, especially Bifidobacteriales genera. This intervention also led to an elevation of gut SCFA levels and mitigated age-related ileac mucosal leakiness in aged recipients. Additionally, it augmented the number of T-helper 2 (Th2) and regulatory T (Treg) cells in the ileum and spleen, with the majority being positive for anti-inflammatory interleukin-10 (IL-10). In sciatic nerves, rejuvenating FMT resulted in increased M2 macrophage counts and a higher IL-10 production by IL-10+TNF-α- M2 macrophage subsets. Ultimately, restoring a youthful gut microbiome in aged mice led to improved nerve repair and enhanced functional recovery after PNI. Considering that FMT is already a clinically available technique, exploring novel translational strategies targeting the gut microbiome to enhance nerve repair in the elderly seems promising and warrants further evaluation.

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.

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.

Pain and numbness one month after carpal tunnel release predict patient-reported outcome measures at sixth months

A number of outcome predictors for carpal tunnel release (CTR) for carpal tunnel syndrome (CTS) have been reported. However, some predictors are controversial, and few studies have referred to the early postoperative outcome prognostic factors after CTR. The aim of this study was to investigate whether pain and numbness at 1 month post-CTR were early postoperative predictors of clinical outcomes 6 months after surgery. Pain and numbness were evaluated using the visual analog scale (VAS) preoperatively and at 1 month post-surgery. Patient-reported outcome measures (PROMs), including the Quick Disabilities of the Arm, Shoulder and Hand (QDASH) measure, the Hand20 questionnaire and the Boston Carpal Tunnel Questionnaire (BCTQ), were recorded for each patient 6 months after surgery. The BCTQ consisted of the Symptom Severity Scale (SSS) and Functional Status Scale (FSS). Multivariable linear regression analysis was performed to investigate the association between the VAS scores and PROMs. We retrospectively identified 93 patients who underwent open carpal tunnel release (OCTR) or endoscopic carpal tunnel release. The mean age of the patients was 67.5 years, and 67 patients (72.0%) were female. Sixty patients were treated by OCTR (65.0%). With multivariable linear regression analysis, we found that pain and numbness, evaluated with VAS 1 month post-surgery had significant correlations with QDASH, Hand20, SSS and FSS 6 months after surgery. In conclusion, pain and numbness 1 month after CTR predict PROMs at 6 months.

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.

A Review of Carpal Tunnel Syndrome and Its Association with Age, Body Mass Index, Cardiovascular Risk Factors, Hand Dominance, and Sex

Carpal tunnel syndrome (CTS) is one of the most common compressive, canalicular neuropathies of the upper extremities, causing hand pain and impaired function. CTS results from compression or injury of the median nerve at the wrist within the confines of the carpal tunnel. Parameters such as age, sex, and body mass index (BMI) could be risk factors for CTS. This research work aimed to review the existing literature regarding the relationship between CTS and possible risk factors, such as age, sex, BMI, dominant hand, abdominal circumference, respiratory rate, blood pressure, and cardiac rate to determine which ones are the most influential, and therefore, take them into account in subsequent applied research in the manufacturing industry. We performed a literature search in the PubMed, EBSCO, and ScienceDirect databases using the following keywords: carpal tunnel syndrome AND (age OR sex OR BMI OR handedness OR abdominal circumference OR respiratory rate OR blood pressure OR cardiac rate). We chose 72 articles by analyzing the literature found based on selection criteria. We concluded that CTS is associated with age, female sex, and high BMI. Trends and future challenges have been proposed to delve into the relationship between risk factors and CTS, such as correlation studies on pain reduction, analysis of weight changes to predict the severity of this pathology, and its influence on clinical treatments.

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.

Risk Factors in Carpal Tunnel Syndrome

We have undertaken a large case–control study using the UK General Practice Research Database to quantify the relative contributions of the common risk factors for carpal tunnel syndrome (CTS) in the community. Cases were patients with a diagnosis of CTS and, for each, four controls were individually matched by age, sex and general practice. Our dataset included 3,391 cases, of which 2,444 (72%) were women, with a mean age at diagnosis of 46 (range 16–96) years. Multivariate analysis showed that the risk factors associated with CTS were previous wrist fracture (OR = 2.29), rheumatoid arthritis (OR = 2.23), osteoarthritis of the wrist and carpus (OR = 1.89), obesity (OR = 2.06), diabetes (OR = 1.51), and the use of insulin (OR = 1.52), sulphonylureas (OR = 1.45), metformin (OR = 1.20) and thyroxine (OR = 1.36). Smoking, hormone replacement therapy, the combined oral contraceptive pill and oral corticosteroids were not associated with CTS. The results were similar when cases were restricted to those who had undergone carpal tunnel decompression.

Dash and Boston Questionnaire Assessment of Carpal Tunnel Syndrome Outcome: What is the Responsiveness of an Outcome Questionnaire?

This prospective study evaluates if the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is an adequately responsive outcome measure in carpal tunnel syndrome by comparing it with the disease-specific Boston questionnaire (BQ). To measure responsiveness (sensitivity to clinical change), 57 patients with a clinical diagnosis of carpal tunnel syndrome completed the DASH and BQ preoperatively and again 3 months after open carpal tunnel decompression. A second group of 31 patients completed the questionnaires in the outpatient clinic and again 2 weeks later to assess test–retest reliability. The time to complete all questionnaires was recorded. Responsiveness of the DASH is comparable with the BQ with standardized response means of 0.66, 1.07 and 0.62 for the DASH, BQ-symptoms and BQ-function, respectively. Test–retest data show both questionnaires are reliable. Mean times to complete questionnaires were 6.8 minutes (DASH) and 5.6 minutes (BQ). This study concludes that the DASH questionnaire is a reliable, responsive and practical outcome instrument in carpal tunnel syndrome.

A Prospective Assessment of Carpal Tunnel Surgery with Respect to Age

Six hundred and thirty five carpal tunnel decompressions in 490 patients were studied prospectively in two hand surgery centres to assess the effect of increasing age on the outcome after surgery. The outcome was assessed using the Levine–Katz carpal tunnel questionnaire, Tinel’s sign, Phalen’s test, Semmes–Weinstein monofilaments and pinch and grip strengths. Assessments were made pre-operatively, at 2 weeks and 6 months postoperatively. Information was also sought concerning co-morbid conditions. Cases were divided into four groups (less than 40 years of age, 40 to 60, 61 to 80, and over 80 years of age). Patients improved significantly in all age groups after carpal tunnel surgery. Despite a relatively high number of co-morbidities, older patients had an acceptable complication rate and their improvement was comparable to all other age groups.

Does aging matter? The efficacy of carpal tunnel release in the elderly

Open release remains the gold standard in the treatment of carpal tunnel syndrome in cases where conservative treatment fails. However, the efficacy of carpal tunnel release in the elderly has been debated in the literature throughout the years. This review aims to review the current evidence pertaining to the efficacy of carpal tunnel release in the elderly. Based on the current evidence, the outcome of carpal tunnel release is unpredictable in the elderly. Elderly patients are also less satisfied with the operation compared to younger patients. The authors recommend that these messages be conveyed to elderly patients before surgery. Moreover, open carpal tunnel release should be offered in the early stages of treatment whenever operative management is indicated.

Carpal tunnel decompression in the super-elderly

There is conflicting evidence about the functional outcome and rate of satisfaction of super-elderly patients (≥ 80 years of age) after carpal tunnel decompression.

We compiled outcome data for 756 patients who underwent a carpal tunnel decompression over an eight-year study period, 97 of whom were super-elderly, and 659 patients who formed a younger control group (< 80 years old). There was no significant difference between the super-elderly patients and the younger control group in terms of functional outcome according to the mean (0 to 100) QuickDASH score (adjusted mean difference at one year 1.8; 95% confidence interval (CI) -3.4 to 7.0) and satisfaction rate (odds ratio (OR) 0.78; 95% CI 0.34 to 1.58). Super-elderly patients were, however, more likely to have thenar muscle atrophy at presentation (OR 9.2, 95% CI 5.8 to 14.6). When nerve conduction studies were obtained, super-elderly patients were more likely to have a severe conduction deficit (OR 12.4, 95% CI 3.0 to 51.3).

Super-elderly patients report functional outcome and satisfaction rates equal to those of their younger counterparts. They are more likely to have thenar muscle atrophy and a severe nerve conduction deficit at presentation, and may therefore warrant earlier decompression.

Cite this article: Bone Joint J 2014; 96-B:1234–8.

Effect of age on subjective complaints and objective severity of carpal tunnel syndrome: prospective study

OBJECTIVES

Older patients with carpal tunnel syndrome who are resistant to conservative treatment often have a less than satisfactory outcome after surgery. We therefore investigated whether the age of the patient affects the subjective complaints or the objective severity of the nerve entrapment prior to surgery in patients younger than 40 years compared with those above 70 years of age.

DESIGN

Prospective study.

SETTING

NHS specialist neurophysiology department.

PARTICIPANTS

One hundred and six splint-resistant patients scored their subjective complaints and scores were then compared with the neurophysiology results.

MAIN OUTCOME MEASURES

Nerve conduction speeds and subjective visual analogue score of pain, sensation and motor function.

RESULTS

Conduction speeds were significantly more affected in patients over 70 years of age than in those under 40 years. Older patients scored their subjective complaints lower than younger patients.

CONCLUSIONS

Older patients' subjective complaints misrepresent the severity of the nerve entrapment. Clinicians should have a lower threshold for objective investigation of patients older than 70 years of age to minimize development of irreversible nerve damage.

Age is an important predictor of short-term outcome in endoscopic carpal tunnel release

Endoscopic carpal tunnel release is a minimally invasive technique that may reduce sick leave and facilitate postoperative rehabilitation and short-term outcome. The aim of this study was to investigate the influence of age as a predictor of short-term outcome in endoscopic carpal tunnel release. We did a prospective registration of patient satisfaction, symptoms and function before and 2-months after endoscopic carpal tunnel release in 101 consecutive patients aged 23-94 years and then submitted the data to multivariable logistic regression analysis. Patient age >65 years was a good predictor of a less favourable short-term outcome, and endoscopic carpal tunnel release may not be justified as a routine procedure in elderly patients.

The Oxford shoulder score revisited

The validated, patient-reported Oxford shoulder score (OSS) was introduced around 10 years ago, primarily for the assessment of outcomes of shoulder surgery (excluding shoulder stabilisation) in randomised trials. Its uptake has steadily increased in a number of countries and its use has also been extended. Recently a number of issues have been raised in relation to other related patient-reported outcome measures which were devised around the same time as the OSS. This included recommendations to change the scoring system. This paper reviews issues concerning patient-reported outcome measures that apply to the OSS and makes some recommendations (including changes to the scoring system) as to how it should be used.

Outcome of carpal tunnel decompression: the influence of age, gender, and occupation

The aim of this study was to investigate the effect of age, gender, and occupation on the outcome of carpal tunnel decompression. A total of 479 patients (342 females, 137 males) with a mean age of 56 years undergoing 608 carpal tunnel decompressions were prospectively studied. Outcome was assessed using the Brigham Hospital carpal tunnel questionnaire at two weeks pre-operatively and six months post-operatively. Cases were divided into four age categories (less than 40 years of age, 40-59, 60-79, and over 80 years of age) and two occupation (repetitive and non-repetitive) groups. The mean differences for both the symptom-severity and functional-status scores amongst the four age categories were similar and no significant difference was found. The mean differences for both the symptom-severity and functional-status scores between females and males and the two occupation groups were similar and no significant differences were found. The majority of the patient's symptoms improved following carpal tunnel decompression. However, we found no influence of age, gender, or occupation on the outcome of carpal tunnel decompression in our series of patients.

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.

Effect of patient age and symptom duration on subjective and objective outcomes of carpal tunnel surgery

This study prospectively examined the relationship between patient age and symptom duration on surgical outcome of carpal tunnel syndrome. Surgical outcomes were evaluated using both subjective and objective measures and statistical analysis was performed using canonical analysis. The result revealed patient age and symptom duration have significant effects on bot subjective and objective outcomes of carpal tunnel surgery.

The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome

In a prospective study, we have evaluated the impact of psychological disturbance on symptoms, self-reported disability and the surgical outcome in a series of 110 patients with carpal tunnel syndrome. Self-reported severity of symptoms and disability were assessed using the patient evaluation measure and the Boston carpal tunnel questionnaire. Psychological distress was assessed using the hospital anxiety and depression scale. There was a significant association between psychological disturbance and the pre-operative symptoms and disability. However, there was no significant association between pre-operative psychological disturbance and the outcome of surgery at six months. We concluded that patients with carpal tunnel syndrome should not be denied surgery because of pre-operative psychological disturbance since it does not adversely affect the surgical outcome.