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Can the outcome of open carpal tunnel release be predicted?:


a review of the literature ans_5175 50..54

Alexandra Turner, Frank Kimble, Károly Gulyás and Jennifer Ball


Royal Hobart Hospital, Hobart, Tasmania

Key words Abstract


carpal tunnel, complications, outcomes, results.
Carpal tunnel syndrome is a common condition affecting 1% of the population. Open
Abbreviations carpal tunnel release is the most commonly performed procedure for this condition.
APB, abductor pollicis brevis; BMI, body mass index; About 70–90% of patients have good to excellent long-term outcomes with open
CTS, carpal tunnel syndrome; OCTD, open carpal tunnel carpal tunnel release. The remainder have poor outcomes. An understanding of factors
decompression; TOS, thoracic outlet syndrome.
which predict a poor outcome following open carpal tunnel release would be of benefit
Correspondence
during preoperative counselling, and provides more accurate expectations of outcomes
Miss Alexandra Turner, Department of Plastic Surgery, after surgery. We reviewed the published literature in the English language over the last
Royal Hobart Hospital, Liverpool Street, Hobart 7004, 20 years in an attempt to ascertain predictors of poor outcomes following open carpal
Tasmania. Email: ajturner@doctors.org.uk tunnel release. Patient factors such as age, sex and weight were not found to be
predictors of a poor outcome following open carpal tunnel release. Similarly, physical
A. Turner MBBS, MRCS; F. Kimble FRACS, FRCS examination had little usefulness, save for abductor pollicis wasting, for predicting
(Eng), FRCS (S.A.) (PLAST), M. Med (Chir); K. Gulyas
post-surgical functional limitations, symptoms or satisfaction. Co-morbid conditions
MD; J. Ball B. App. Sc. (physio), CHT.
such as diabetes, poor health status, thoracic outlet syndrome, double crush, alcohol
The corresponding author is not a recipient of a and smoking have a worse prognosis. Normal nerve conduction studies preoperatively,
research scholarship. direct nerve surgery such as neurolysis, abductor pollicis brevis muscle wasting and
workers’ compensation cases which involve lawyers preoperatively are all associated
The paper is not based on a previous communication to with worse outcomes. Postoperative physiotherapy may accelerate recovery but
a society or meeting. neither modifies functional recovery or reduces symptom occurrence.
Accepted for publication 4 March 2009.

doi: 10.1111/j.1445-2197.2009.05175.x

Introduction Assessment of postoperative outcomes has become increasingly


important in the last 10–15 years.4. Few studies of open carpal tunnel
Carpal tunnel syndrome (CTS) is a common condition affecting 1%
release, however, have measured outcomes which matter most to the
of the population.1
patient, namely, relief of symptoms, improved function and patient
The gold standard technique for the management of this condition
satisfaction.5 Furthermore, there exist limitations on predictors of
is open release of the transverse carpal ligament. An alternative
outcomes in the published literature: many are retrospective analy-
approach is endoscopic release but is not discussed further in this
ses, which make analyses of pre-surgical factors such as symptom
paper.
severity, functional status and mental health less meaningful.
About 70–90% of patients have good to excellent long-term out-
In this paper, we have reviewed the published literature in the
comes with open carpal tunnel release.2 The remainder have poor
English language over the last 20 years in an attempt to ascertain
outcomes, which can be classified into one of three categories:
predictors of poor outcomes following open carpal tunnel release.
persistent, recurrent or new symptoms.3 Some poor outcomes are
because of surgical error (inadequate release, nerve injury) and are
Methods
not discussed in this paper. Poor outcomes for other reasons remain
the chagrin of hand surgeons. An understanding of factors which A Pubmed/Medline search of outcomes of carpal tunnel release was
predict a poor outcome following open carpal tunnel release would performed looking at all original articles and reviews in the English
be of benefit during preoperative counselling, and provides more language over the last 20 years. A Cochrane review was performed
accurate expectations of outcomes after surgery. but failed to reveal any relevant reviews on the subject. Key words

© 2010 The Authors


ANZ J Surg 80 (2010) 50–54 Journal compilation © 2010 Royal Australasian College of Surgeons
Predicting the outcome of carpal tunnel release 51

used in the Medline search included: ‘open carpal tunnel release’, anatomical factors but on internal factors such as metabolic (glycae-
‘outcomes’, ‘complications’ and ‘results’. With the search engine mic) and vascular causes, and that its treatment should include the
results, the authors convened as a group analysing each abstract to correction of these factors.
ensure its relevance to our paper. The selected abstracts were then
used to retrieve the complete original articles for further analysis. Poor health status
Cross referencing of the original articles was also applied, and the Health status has been measured using various assessment tools.
relevant articles were retrieved. However, regardless of the type (Nottingham Health Profile Ques-
From all the articles, we made a list of all possible factors cited as tionnaire, General Physical Health Score), authors have reported a
a measure of outcome. We then divided them into four main catego- greater incidence of complications and a prolonged follow-up in
ries: patient factors (age, sex, etc.), co-morbid factors (diabetes, patients of poor health status.21–23
pregnancy, etc.), physical findings (nerve conduction studies, hour- The advice in this subset of patients, in the first instance, is
glass deformity, etc.) and other factors (workers’ compensation, conservative management.
etc.).
The selected articles were then studied to ascertain the influence Thoracic outlet syndrome
of each cited factor in predicting outcome following open carpal Patients whose CTS is associated with thoracic outlet syndrome
tunnel release. (TOS) have an abysmal prognosis, with some authors reporting an
80% chance of a poor outcome.24

Results Pregnancy, contraceptive pills, rheumatoid arthritis


Few authors mention pregnancy, contraceptive pills and rheumatoid
Patient factors (age, sex, body mass index) arthritis as risk factors for CTS, but these conditions are not predic-
While it is recognized that gender and obesity are firmly associated tive of a poor postoperative outcome.24,25.
with the development of CTS,6–9 there is as yet, no established link
between certain patient factors such as gender, age, body mass index Double crush
(BMI) and predicting outcomes. Double or multiple crush syndromes is clearly associated with the
A number of authors have investigated the influence of age on presence of suboptimal results. Symptoms and/or signs of cervical
postoperative outcome.10–15 Hobby et al.13 and Townshend et al.12 spine disease were present in 81% of the poor results after carpal
noticed that in individuals over 60–70 years of age, the greater the tunnel release.26 The authors of this paper suggest appropriate treat-
severity of symptoms, the less successful the outcome. ment of both lesions in double crush.
Hobby et al.13 also noted greater preoperative symptoms and However, Choi and Ahn18 found that even in patients whose elec-
disability in women, but no significant differences were noted in tromyogram revealed double crush syndrome, these pateints still
postoperative outcomes between the two genders. showed improvement, with good-to-excellent results in 11 out of 15
There is no overwhelming evidence to suggest that either gender, cases.
BMI and to a lesser extent, age, has a direct influence on postopera-
tive outcomes in open carpal tunnel decompression (OCTD). Habits
Results may be less predictable in patients over 70 years of age, Cigarrette smoking and alcohol consumption (more than two drinks
but the high satisfaction rate (94%) reported among this subset of per day)are associated with worse functional outcomes and more
patients15 indicates continued objective benefit from performing this severe symptoms at follow up.27
operation on people over 70 years of age, in combination with
Physical findings include:
appropriate counselling preoperatively.
Duration of symptoms, nerve conduction studies, operative findings,
Co-morbid factors abductor pollicis brevis (APB) muscle atrophy, postoperative
physiotherapy.
Diabetes
The incidence of CTS in diabetics has been reported to be as high as Duration of symptoms
15–33%,14,15 10-fold higher than the general population.16 However, Earlier authors, and later, Destafano et al., Bland and Choi and
the postoperative outcome is not quite so predictable. Both Phalen17 Ahn,6,18,28 found that patients with the shortest duration of symptoms
and Choi and Ahn18 believed diabetes did not adversely affect the recovered faster than the long-duration groups. Aulisa et al.29 and
surgical outcome, with Choi and Ahn showing improvement (with Luchetti et al.30 established that complete nerve recovery was likely,
good-to-excellent results) in 14 out of 19 patients (74%). only if surgery was performed at a very early stage of compression.
Al-Qattan et al.19 found that 25% of diabetic patients had a poor Other authors have disputed any association between duration of
outcome (although there was a similar total to non-diabetics), and all symptoms and predicting outcome post-surgery.30,31–34
reporting an element of postoperative numbness. These patients,
interestingly, had little or no evidence of localized compression on Nerve conduction studies
nerve conduction studies preoperatively. There is a vast array of opinions regarding the value of nerve
Ozkul et al.20 endorse carpal tunnel release in diabetic patients but conduction studies (NCS) in diagnosing/assessing outcomes in
warn readers that the condition is dependent not only on external– CTS.24–30,35–42

© 2010 The Authors


Journal compilation © 2010 Royal Australasian College of Surgeons
52 Turner et al.

A popular concept is that the absence of abnormality in NCS compared with Medicare patients and other groups, but mention
predicts a poor outcome in carpal tunnel release, but if the nerve different percentages of poor outcome (38–53%).8,44,47,48
conduction study is abnormal, then there is no significant association The Maine Carpal Tunnel Study22 showed that involvement of an
between the level of abnormality and the outcome of carpal tunnel attorney preoperatively predicted a worse outcome, and in compen-
decompression.28,31,32,38,42,43 Other authors believe that there is no sation cases where attorneys were not involved, outcomes were the
benefit in obtaining NCS when attempting to predict outcome, and same as for the general population following carpal tunnel release.
may in fact be seen as a confounding factor by some.36,39–42

Hourglass deformity Surgeon training


The presence of hourglass deformity itself does not necessarily A few articles make mention of surgeon experience but none found
mean that the compression is more advanced, more severe or of any correlation between outcomes and the surgeon’s level of
longer duration. Arons et al.31 concludes that the hourglass compres- training.2,8,22
sion of the median nerve is not a negative prognostic indicator.

Surgical technique
Neurolysis Repairing the transverse carpal ligament has been shown to provide
Chapell et al.’s32 recent result of the meta-analysis of global out- an excellent recovery of grip strength,49–51 particularly in patients
comes of epineurotomy in carpal tunnel release indicates that neural who had a transposition flap repair of the carpal ligament.49
surgery is associated with poorer global outcomes and is potentially Netscher et al.,50 also showed that tendon excursion/digital flexion
harmful for most patients with CTS. improved following transposition flap repair of the transverse carpal
ligament.
Abductor pollicis brevis muscle atrophy
Atrophy of abductor pollicis brevis (APB) before surgery appeared
to be an indicator of poor surgical prognosis. Patients with pre-
existing atrophy of APB more often failed to obtain long-term relief
Discussion
of median nerve paraesthesia post-surgery,30,33,34 although Mondelli When we set out to write this paper, we sought to find factors which
et al.43 was able to prove that it is still possible to obtain good were predictive of a poor outcome following open carpal tunnel
clinical and electrophysiological results even in extreme cases of release. Our aim was to identify those patients preoperatively who
CTS. may get a poor outcome and thereby assist patients in the informed
consent process, by providing realistic expectations of outcomes and
Postoperative physiotherapy perhaps produce a document of some use in legal opinions. We
Pomerance and Fine44 found no difference in return to work times found a number of flaws in the methodology of papers, namely, a
between those with or without postoperative physiotherapy. Further- lack of prospective studies, variation in the assessment of outcome,
more, there was no significant difference in grip strength, pinch small population groups and lack of sufficient follow-up. Despite the
strength or pain postoperatively between the two groups. obvious deficiencies, we were able to ascertain that poor outcomes
Other authors have found that postoperative rehabilitation accel- following open carpal tunnel release were not related to patient
erates recovery but neither modifies functional recovery or reduces factors such as age, sex or weight. Even those elderly individuals
symptom occurrence.11,45,46 with severe preoperative NCS abnormalities should not be excluded
from surgery, as they are still likely to be satisfied with surgery,
Other factors (occupation, workers particularly if realistic expectations about surgical outcomes are
compensation, surgeon training, established at the outset.
surgical technique) Co-morbid conditions such as diabetes, poor health status, TOS,
double crush, alcohol and smoking have a worse prognosis.
Occupation Of the physical factors, clinical examination had little usefulness
Nathan et al.47 found no work factors to be even marginal predictors for predicting postsurgical functional limitations, symptoms or sat-
of CTS, although odds ratios and P values suggested that CTS was isfaction. However, normal NCS preoperatively, direct nerve surgery
significantly related to repetitive work, and marginally, but not sig- such as neurolysis and APB muscle wasting are associated
nificantly, related to heavy lifting, and vibratory tools. with worse outcomes. Workers’ compensation cases which involve
Patients with occupationally caused CTS had a three times slower lawyers preoperatively have poor outcomes. Table 1 summarizes
recovery and remained off work five times longer than those with these factors.
non-occupationally induced CTS, but in the long term, outcomes Postoperative physiotherapy may accelerate recovery but neither
were no different.27,37,38 modifies functional recovery nor reduces symptom occurrence.
Clearly, there is still a need for well-designed prospective studies
Workers’ compensation using agreed measures of outcome, particularly those that matter
All authors agree that patients covered by workers’ compensation most to the patient, namely, relief of symptoms, improved function
insurance are slower to return to both modified and regular work and overall satisfaction.

© 2010 The Authors


Journal compilation © 2010 Royal Australasian College of Surgeons
Predicting the outcome of carpal tunnel release 53

Table 1 Predictive factors for poor outcome 15. Celiker R, Basgoze O, Bayraktar M. Early detection of neurological
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Co-morbid factors Diabetes 1996; 36: 29–35.
Poor health status 16. Atroshi I, Gummesson C, Jhonsson R, Ornstein E, Ranstam J, Rosen I.
Smoking, alcohol Prevalence of carpal tunnel syndrome in general population. JAMA
Misdiagnosis TOS 1999; 282: 153–8.
Double crush
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Physical findings APB muscle atrophy hands. Clin. Orthop. 1972; 83: 29–40.
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APB, abductor pollicis brevis; TOS, thoracic outlet syndrome. Plast. Reconstr. Surg. 1998; 102: 2374–80.
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20. Ozkul Y, Sabuncu T, Kocabey Y. Outcomes of carpal tunnel release in
Despite the level of evidence being weak for most of the articles
diabetic and non-diabetic patients. Acta Neurol. Scand. 2002; 106: 168–
cited in this paper, in the absence of any stronger evidence-based 72.
studies, we feel that this article offers an important source of mate- 21. Rege AJ, Sher JL. Can the outcome of carpal tunnel release be pre-
rial for informed consent. dicted? J. Hand Surg. 2001; 26B: 148–50.
22. Katz JN, Keller RB, Simmons BP et al. Maine carpal tunnel study:
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© 2010 The Authors


Journal compilation © 2010 Royal Australasian College of Surgeons