5,557

Short-Term Outcomes after Median Nerve Release for Carpal Tunnel Syndrome

Andrea Dominguez, Laura Lucía Mira, Andrea Sallent, Roberto Seijas, Carles Escalona, Ramón Cugat, Oscar Ares

Andrea Dominguez, Medical Student, Autonoma University of Barcelone, Spain
Laura Lucía Mira, Roberto Seijas, Ramón Cugat, Orthopedic Surgery, Garcia Cugat Foundation Quiron Hospital Barcelone, Spain
Andrea Sallent, Vall Hebron Hospital Barcelone, Spain
Laura Lucía Mira, Roberto Seijas, Carles Escalona, Oscar Ares, Basic Sciences Department, International University of Catalunya, Spain
Oscar Ares, Hospital Clinic Barcelona, Spain

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Roberto Seijas, MD, PhD, Quiron Hospital Barcelona, Pza. Alfonso Comín 5-7, 08035 Barcelone, Spain.
Email: roberto6jas@gmail.com
Telephone: +34932172252
Fax: +34932381634

Received: February 9, 2017
Revised: April 19, 2017
Accepted: April 21 2017
Published online: June 28, 2017

ABSTRACT

AIM: To study the short-term (considered as a 1-month period after surgery) outcomes experienced by patients following median nerve release due to carpal tunnel syndrome.

MATERIAL AND METHODS: A longitudinal cohort study was performed between September 2013 and October 2014. Inclusion criteria included suffering from CTS for at least six months confirmed by clinical and electromyographyc criteria and undergoing median nerve release. Exclusion criteria were pregnancy, patients with acute CTS and patients who were not able to read or non-Spanish speakers. All participants completed the questionnaires DASH, SF-36 and a Visual Analogue Scale for Pain, preoperatively and one month after surgery.

RESULTS: Thirty patients were included, 22 women and 8 men. DASH and VAS showed statistical significant differences before and after surgery (p < 0.05) whereas SF-36 did not show significant differences.

CONCLUSION: This study shows that median nerve surgical release for CTS has satisfying outcomes in only one month from surgery.

Key words: Carpal tunnel release; Short term outcomes; SF-36; DASH; Functional outcomes

© 2017 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Dominguez A, Mira LL, Sallent A, Seijas R, Escalona C, Cugat R, Ares O. Short-Term Outcomes after Median Nerve Release for Carpal Tunnel Syndrome. International Journal of Orthopaedics 2017; 4(3): 758-762 Available from: URL: http: //www.ghrnet.org/index.php/ijo/article/view/1986

INTRODUCTION

The American Academy of Orthopaedic Surgeons (AAOS) defines carpal tunnel syndrome (CTS) as “symptomatic compressive neuropathy of the median nerve at the wrist.”[1,2]. CTS is the most frequent compression peripheral neuropathy in the hand. It is estimated to affect 3.8% of the general population[3] with an incidence of 276: 100,000 a year[4]. It occurs more frequently in women, with a prevalence of 9.2% among women and 6% in men[2,5]. CTS is the most popular and common form of compression of the median nerve[1,6-8] and it makes up for 90% of all compression neuropathies[9]. Symptoms of compression of the median nerve at the wrist were first described by Sir James Paget in 1854, in a patient who had suffered a fracture of the distal radius[10,11].

It is known that surgical release of median nerve can decrease pain, improve grip strength and furthermore, patients’ expectations meet with the surgical outcomes[12-14] this results can be evaluated even one week after surgery[15].

Functional results are usually evaluated in medium term being 3, 6 and 12 months after surgery the most common periods[15-19].

Due to the high prevalence of CTS, the present study aimed to study the short-term outcomes experienced by patients following median nerve release. Short-term was considered as a 1-month period after carpal tunnel decompression.

MATERIAL AND METHODS

A longitudinal cohort study was performed between September 2013 and October 2014 using repeated measures of the outcomes experienced by patients. All participants were informed that data regarding their case would be used for further research and agreed to. Oral and written informed consent was obtained from all patients.

Inclusion criteria included suffering from CTS for at least six months confirmed by clinical and electromyographyc criteria and undergoing median nerve release. Exclusion criteria were pregnant women, patients with acute CTS and patients who were not able to read or non-Spanish speakers.

Patients in the present study underwent local anaesthesia with 3 ml of 2% Mepivacaine applied one / two centimetres proximal to the radiocarpal joint between the palmaris longus muscle and the flexor carpi radialis, plus 1ml subcutaneous in the incision area (Madden technique). The flexor retinaculum was identified and opened, checking the absence of any tumour that could be favouring the nervous compression. Neurolysis was not associated in any case. The surgical procedure was done without tourniquet. The same surgical team always carried out this intervention. After closing with nonabsorbable sutures a compressive bandage was placed. One week after surgery both the sutures and the compressive bandage was removed.

All participants completed the questionnaires DASH [20,21], SF-36[22] as well as a Visual Analogue Scale for Pain (VAS Pain) preoperatively and one month after surgery.

The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, translated and validated into Spanish[20], is a specific measurement of quality of life related to upper limb problems, being 0 no disability at all and 100 the highest disability possible. Thus, the higher the score, the greater disability experienced by the patient.

The SF-36 questionnaire, translated and validated into Spanish[22], provides an overview of the quality of life of the patient, easily filled out by the patient and evaluated by a standard statistical system. It contains 36 questions that address different aspects of daily life and are grouped and measured in 8 sections that are assessed independently and lead to 8 dimensions measured by the questionnaire. Scores for each of the 8 dimensions of the SF-36 have values ​​ranging between 0 and 100. The higher the score the better the health is. These 8 scales are grouped into two aspects, physical and mental.

Statistical Analysis

Paired data from pre and post-surgical questionnaires were collected and the analysis was performed using the SPSS V20 program.

A descriptive study of the variables degree of upper limb disability, quality of life both physical and mental and pain was performed.

A study of normality of variables was performed using the Kolmogorov-Smirnov test, obtaining that variables ‘preoperative VAS Pain’, ‘preoperative DASH’, ‘preoperative SF-36 Mental’, ‘preoperative SF-36 physical’ and ‘postoperative SF-36 physical’ do not follow a normal distribution. On the other hand, variables ‘postoperative VAS Pain’, ‘postoperative DASH’ and ‘postoperative SF-36 Mental’ do follow a normal distribution.

Nonparametric tests were used for those variables that did not follow a normal distribution. Inferential analysis of the data was performed using the Wilcoxon test testing for DASH, SF-36 and VAS Pain preoperative and postoperative.

Results were considered significant at p < 0.05.

Within the sample size, a group of 30 patients was chosen to detect with 70% strength and odds ratio of 3.5, using Chi-squared test and an estimated 5% for statistical significance.

RESULTS

Thirty patients met the inclusion-exclusion criteria and were included in the present study, 22 women and 8 men. There was no exclusion in the 30 patients selected at first.

Figure 1 shows the statistically significant values of DASH questionnaire before and after surgery, measuring the degree of disability. Figure 2 and 3 show the outcomes observed within the SF-36 questionnaire, with no significant differences before and after surgery. Pain measured with VAS showed significant differences one month after surgery (Figure 4).

Figure 1. DASH outcomes before (PreOp) and after (PostOp; one month) surgery. Statistically significant differences (p < 0.0001) were observed one month after the procedure. Having an average value before surgery (pre) of 49.25 (SD 25.06) and one month after surgery (post) of 23.89 (SD 20.00).

Figure 1 DASH outcomes before (PreOp) and after (PostOp; one month) surgery.

Figure 2. Outcomes for the SF-36 Mental component before (PreOp) and after surgery at one month (PostOp). No significant differences were observed (p = 0.069), being the preoperative score of 42.87 (SD 8.7) and the postoperative of 40.52 (SD 7.29). A trend towards improvement of the mental SF-36 exists within one month after surgery.

Figure 2 Outcomes for the SF-36 Mental component before (PreOp) and after surgery at one month (PostOp).

Figure 3. SF-36 Physical component before (PreOp) and after surgery at one month (PostOp). Non-significant differences (p = 0.136) were observed between the preoperative score (42.87; SD 8.7) and one month after surgery (45.55; SD 14.20).

Figure 3 SF-36 Physical component before (PreOp) and after surgery at one month (PostOp).

Figure 4. Pain measured with VAS before (PreOp) and one month after surgery (PostOp). Significant differences (p < 0.0001) were observed.

Figure 3 SF-36 Physical component before (PreOp) and after surgery at one month (PostOp).

DISCUSSION

CTS surgery represents an early improvement to the patient in terms of specific quality of life questionnaires (DASH and VAS). The present study aimed to study that decompression surgery of the median nerve improves the quality of life of patients suffering CTS in the short term.

As abovementioned, surgical release of the median nerve has a high rate of patients’ satisfactory results 3, 6 months and 1 year after surgery[16-18]. Some series show satisfactory resuls at one and three weeks after surgery [13,15].

However, our aim was to go one step further evaluating how soon the patient actually experiences this improvement. Thus, the purpose of the present study was to evaluate, if any, the possibility of any change in quality of life of patients after only one month.

Our patients frequently demand a very early incorporation to their work duties. Given the observed outcomes in the present study, with satisfactory outcomes in less than a month, we can suggest reincorporation to work duties in a short period of time.

One month after surgery there is a significant difference in the VAS Pain and DASH, whereas the SF-36 does not show significant differences either on the mental or physical group, at least not in just one month. Among the most important findings of our study, the scales show the impact that surgery has at a specific level only one month after surgery. Pain as well as degree of disability of the person improves in a short-term period. However, the effect on the quality of life however, may need some more time.

Ralph compared SF36, DASH and CTQ and it concluded that DASH and CTQ were much more sensitive to change at 12 weeks of follow-up. CTQ and DASH seems to have good correlation in 6 weeks follow up but SF36 does not[23]. Also Uchiyama show similar results[3].

These results are in line with those published by Amirfyez et al, who evaluated at 6 weeks after surgery using the DASH questionnaires, with significant improvement in their series[24]. Our aim is to see whether this improvement can be evaluated at 4 weeks.

Recent studies show the high correlation between the DASH questionnaire and resolution of pain and paraesthesia[25]. The validation studies into Spanish show great validity in their construction with a great sensibility to change in pain[26]. The study of Gay et al even advised to have the DASH performed as a single test, in a study at 6 and 12 weeks of evaluation[23].

Other publication observed that SF36 has limitations in capturing upper extremity disability[27] Amadio et all shows that 3 months after surgery of the nine SF-36 scales studied, significant changes occurred in three: the physical role, emotional role, and pain scales. Each of these scales changed in the direction of improved health status after carpal tunnel release. The largest effect was in the pain scale. Their results with the SF-36 show effect sizes in the pain and physical role scales (preoperative to postoperative change, as measured in standardized differences) similar to those reported by Ware et al for heart surgery[28], Kantz et al for knee replacement[29], Liang et al for hip replacement[30], and Lansky et al for back pain[31]. The magnitude of the preoperative SF-36 physical role scale deviations from norms lies between those reported by Ware et al[28]. For minor and major medical conditions.

Of particular interest is the responsiveness of two subscales of a general instrument such as the SF-36 to the unilateral impairment of the upper extremity caused by carpal tunnel syndrome. The magnitude of change suggests that the health impact of carpal tunnel syndrome is considerable. This responsiveness permits SF-36 and AIMS2 to assess the relative impact of carpal tunnel syndrome compared with that of other pathologic processes[19].

As we can see SF36 is useful in the follow-up but it has limitations for very short term outcomes. The results can be observed at least one month after surgery. Other scales must be used before that month.

Several limitations of the study must be taken into consideration when reviewing the current study. First, its limited number of patients, with a larger sample it is possible that smaller variations could have been detected. The design limitation is the fact that we have sought differences in just one month, maybe in three months the quality of life has a significant difference. Also, we do not know if the fact that patients have had to suffer CTS for at least six months can be a factor and alter somewhat the SF-36, it was observed that the SF-36 of this subgroup of patients was altered compared to the normal population[32], some authors do not recommend using the SF-36 to monitor the state of health in individuals who undergo trauma surgery [33], a new and more specific scale could be designed for these patients.

The most powerful prediction factor of satisfaction in the CTS release is the improvement of the symptoms, and these carry an increased optimism and improvements in patients expectations[34].

CONCLUSION

This study shows that median nerve surgical release for CTS has satisfying outcomes in only one month from surgery.

REFERENCES

1. Keith MW, Masear V, Chung KC, Maupin K, Andary M, Amadio PC, Watters WC 3rd, Goldberg MJ, Haralson RH 3rd, Turkelson CM, Wies JL, McGowan R. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2009 Oct; 91(10): 2478-2479. [DOI: 10.2106/JBJS.I.00643]; [PMID: 19797585]

2. Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal tunnel syndrome: a review of the recent literature. Open Orthop J. 2012; 6: 69-76. [DOI: 10.2174/1874325001206010069]. Epub 2012 Feb 23. [PMID: 22470412]; [PMCID: PMC3314870]

3. Uchiyama S, Itsubo T, Nakamura K, Kato H, Yasutomi T, Momose T. Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation. J Orthop Sci. 2010 Jan; 15(1): 1-13. [DOI: 10.1007/s00776-009-1416-x]. Epub 2010 Feb 12. Review. [PMID: 20151245]

4. Mondelli M, Giannini F, Giacchi M. Carpal tunnel syndrome incidence in a general population. Neurology. 2002 Jan 22; 58(2): 289-294. [PMID: 11805259]

5. Rask MR. Anterior interosseous nerve entrapment: (Kiloh-Nevin syndrome) report of seven cases. Clin Orthop Relat Res. 1979 Jul-Aug; (142): 176-181. [PMID: 498633]

6. Padua L, Lo Monaco M, Padua R, Gregori B, Tonali P. Neurophysiological classification of carpal tunnel syndrome: assessment of 600 symptomatic hands. Ital J Neurol Sci. 1997 Jun; 18(3): 145-150. [PMID: 9241561]

7. Saleh Rasras, Soheil Fallahpour, Seyed Reza Saeidian, Masud Zeinali AA. Prevalence of Concurrent Disorders of Ulnar Nerve Entrapment at the Elbow and Carpal Tunnel Syndrome Ahvaz Imam Khomeini Hospital During 2009 to 2012. Int J Adv Biol Biomed Res. 2014; 2(6): 1991-1996.

8. Lo SL, Raskin K, Lester H, Lester B. Carpal tunnel syndrome: a historical perspective. Hand Clin. 2002 May; 18(2): 211-217, v. Review. [PMID: 12371024]

9. Aroori S, Spence RA. Carpal tunnel syndrome. Ulster Med J. 2008 Jan; 77(1): 6-17. Review. [PMID: 18269111]; [PMCID: PMC2397020]

10. Paroski MW, Fine EJ. Sir James Paget and the carpal tunnel syndrome. Neurology. 1985 Mar; 35(3): 448. [PMID: 3883238]

11. Paget J. The first description of carpal tunnel syndrome. J Hand Surg Eur Vol. 2007 Apr; 32(2): 195-197. Epub 2007 Feb 12. [PMID: 17296253]

12. Becker SJ, Makanji HS, Ring D. Expected and actual improvement of symptoms with carpal tunnel release. J Hand Surg Am. 2012 Jul; 37(7): 1324-1329.e1-5. [DOI: 10.1016/j.jhsa.2012.03.039]; [PMID: 22721456]

13. Atroshi I, Larsson GU, Ornstein E, Hofer M, Johnsson R, Ranstam J. Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial. BMJ. 2006 Jun 24; 332(7556): 1473. Epub 2006 Jun 15. [PMID: 16777857]; [PMCID: PMC1482334]

14. Castillo TN, Yao J. Prospective randomized comparison of single-incision and two-incision carpal tunnel release outcomes. Hand (N Y). 2014 Mar; 9(1): 36-42. [DOI: 10.1007/s11552-013-9572-z]; [PMID: 24570635]; [PMCID: PMC3928372]

15. Macdermid JC, Richards RS, Roth JH, Ross DC, King GJ. Endoscopic versus open carpal tunnel release: a randomized trial. J Hand Surg Am. 2003 May; 28(3): 475-480. [PMID: 12772108]

16. Gong HS, Oh JH, Bin SW, Kim WS, Chung MS, Baek GH. Clinical features influencing the patient-based outcome after carpal tunnel release. J Hand Surg Am. 2008 Nov; 33(9): 1512-1517. [DOI: 10.1016/j.jhsa.2008.05.020]; [PMID: 18984332]

17. Badger SA, O’Donnell ME, Sherigar JM, Connolly P, Spence RA. Open carpal tunnel release--still a safe and effective operation. Ulster Med J. 2008 Jan; 77(1): 22-24. [PMID: 18269113]; [PMCID: PMC2397012]

18. Lindau T, Karlsson MK. Complications and outcome in open carpal tunnel release. A 6-year follow-up in 92 patients. Chir Main. 1999; 18(2): 115-121. [PMID: 10855309]

19. Amadio PC, Silverstein MD, Ilstrup DM, Schleck CD, Jensen LM. Outcome assessment for carpal tunnel surgery: the relative responsiveness of generic, arthritis-specific, disease-specific, and physical examination measures. J Hand Surg Am. 1996 May; 21(3): 338-346. [PMID: 8724457]

20. Hervás MT, Navarro Collado MJ, Peiró S, Rodrigo Pérez JL, López Matéu P, Martínez Tello I. [Spanish version of the DASH questionnaire. Cross-cultural adaptation, reliability, validity and responsiveness]. Med Clin (Barc). 2006 Sep 30; 127(12): 441-447. Spanish. [PMID: 17040628]

21. Rosales RS, Delgado EB, Díez de la Lastra-Bosch I. Evaluation of the Spanish version of the DASH and carpal tunnel syndrome health-related quality-of-life instruments: cross-cultural adaptation process and reliability. J Hand Surg Am. 2002 Mar; 27(2): 334-343. [PMID: 11901395]

22. Alonso J, Prieto L, Antó JM. [The Spanish version of the SF-36 Health Survey (the SF-36 health questionnaire): an instrument for measuring clinical results]. Med Clin (Barc). 1995 May 27; 104(20): 771-776. Spanish. [PMID: 7783470]

23. Gay RE, Amadio PC, Johnson JC. Comparative responsiveness of the disabilities of the arm, shoulder, and hand, the carpal tunnel questionnaire, and the SF-36 to clinical change after carpal tunnel release. J Hand Surg Am. 2003 Mar; 28(2): 250-254. [PMID: 12671856]

24. Amirfeyz R, Pentlow A, Foote J, Leslie I. Assessing the clinical significance of change scores following carpal tunnel surgery. Int Orthop. 2009 Feb; 33(1): 181-185. Epub 2007 Oct 31. [PMID: 17972075]; [PMCID: PMC2899221]

25. Yücel H, Seyithanoğlu H. Choosing the most efficacious scoring method for carpal tunnel syndrome. Acta Orthop Traumatol Turc. 2015; 49(1): 23-29. [DOI: 10.3944/AOTT.2015.13.0162]; [PMID: 25803249]

26. Rosales RS, Diez de la Lastra I, McCabe S, Ortega Martinez JI, Hidalgo YM. The relative responsiveness and construct validity of the Spanish version of the DASH instrument for outcomes assessment in open carpal tunnel release. J Hand Surg Eur Vol. 2009 Feb; 34(1): 72-75. [DOI: 10.1177/1753193408094156]; Epub 2008 Dec 17]; [PMID: 19091735]

27. Katz JN, Losina E, Amick BC 3rd, Fossel AH, Bessette L, Keller RB. Predictors of outcomes of carpal tunnel release. Arthritis Rheum. 2001 May; 44(5): 1184-1193. [PMID: 11352253]

28. John E. Ware, Kristin K. Snow, Mark Kosinski BG. SF-36 health survey: manual and interpretation guide. Institute: The Health, editor. Boston: New England Medical Center; 1993.

29. Kantz ME, Harris WJ, Levitsky K, Ware JE Jr, Davies AR. Methods for assessing condition-specific and generic functional status outcomes after total knee replacement. Med Care. 1992 May; 30(5 Suppl): MS240-52. [PMID: 15839363]

30. Liang MH, Fossel AH, Larson MG. Comparisons of five health status instruments for orthopedic evaluation. Med Care. 1990 Jul; 28(7): 632-42; [PMID: 2366602]

31. Lansky D, Butler JB, Waller FT. Using health status measures in the hospital setting: from acute care to ‘outcomes management’. Med Care. 1992 May; 30(5 Suppl): MS57-73. [PMID: 1533890]

32. Atroshi I, Gummesson C, Johnsson R, Sprinchorn A. Symptoms, disability, and quality of life in patients with carpal tunnel syndrome. J Hand Surg Am. 1999 Mar; 24(2): 398-404. [PMID: 10194028]

33. Busija L, Osborne RH, Nilsdotter A, Buchbinder R, Roos EM. Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery. Health Qual Life Outcomes. 2008 Jul 31; 6: 55. [DOI: 10.1186/1477-7525-6-55]; [PMID: 18667085]; [PMCID: PMC2527304]

34. Kadzielski J, Malhotra LR, Zurakowski D, Lee SG, Jupiter JB, Ring D. Evaluation of preoperative expectations and patient satisfaction after carpal tunnel release. J Hand Surg Am. 2008 Dec; 33(10): 1783-1788. [DOI: 10.1016/j.jhsa.2008.06.019]; [PMID: 19084178]

Peer reviewer: Scott Fried

Refbacks

  • There are currently no refbacks.


Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.