Standard Open Decompression in Carpal Tunnel Syndrome Compared With a Modified Open Technique Preserving the Superficial Skin Nerves: A Prospective Randomized Study

doi:10.1016/j.jhsa.2006.07.018

The Journal of Hand Surgery

Volume 31, Issue 9, November 2006, Pages 1483-1489

https://doi.org/10.1016/j.jhsa.2006.07.018 Get rights and content

Purpose

A common surgical treatment for carpal tunnel syndrome is open carpal tunnel decompression. This involves skin incision followed by sharp dissection straight down through fat and palmar fascia to the transverse carpal ligament, which is then divided. The incidence of scar discomfort ranges from 19% to 61%, and its cause is not fully understood. We conducted a prospective randomized controlled trial to investigate whether preservation of superficial nerve branches crossing the incision site reduces the incidence and severity of postoperative scar pain after open carpal tunnel release.

Methods

Forty-two patients with bilateral idiopathic carpal tunnel syndrome (84 hands) were included in the study. The patients were randomized to determine which hand was to have carpal tunnel decompression using a technique that would try to preserve the superficial nerve branches. The other hand had open carpal tunnel decompression without any attempt to preserve the superficial nerve branches. An assessment of each hand in each patient was performed immediately before surgery and at 6 weeks, 3 months, and 6 months after surgery. This assessment was performed with a questionnaire based on the Patient Evaluation Measure.

Results

We found no evidence of a difference in scar pain between the 2 methods at 6 weeks, 3 months, and 6 months. There was a significant difference in the length of surgery between the 2 groups.

Conclusions

Scar pain scores in this series of open carpal tunnel decompressions were similar, whether or not an attempt was made to identify and preserve superficial nerve branches crossing the wound.

Type of study/level of evidence

Therapeutic I.

Section snippets

Materials and Methods

Between 2004 and 2005, 42 patients with bilateral idiopathic carpal tunnel syndrome (84 hands) were recruited into this study. Inclusion criteria were (1) bilateral painful paresthesia in the hand, (2) loss of sensibility in the median nerve distribution, (3) a positive Tinel sign over the median nerve, and (4) a positive Phalen test result. Exclusion criteria were (1) previous carpal tunnel surgery, (2) inflammatory arthropathy and/or peripheral neuropathy, (3) spine/shoulder or elbow

Results

All 42 patients in the study (84 hands) were followed up with the questionnaire for the complete 6 months of the study period.

We found no difference in the PEM scores between the 2 groups of hands (SCTD, NPCTD) at 6 weeks (p = .93), 3 months (p = .43), and 6 months (p = .38) (Fig. 2).

Furthermore we found no evidence of a difference in scar pain between the 2 groups of hands at 6 weeks (p = .73), 3 months (p = .59), and 6 months (p = .13) (Fig. 3). There was a significant difference in the

Discussion

Carpal tunnel decompression is a widely practiced and safe procedure with good long-term results. Various investigators have tried to improve on excellent results and reduce common postoperative complaints such as scar discomfort. In a randomized controlled trial, Ferdinand and MacLean¹³ compared endoscopic with open carpal tunnel decompression in patients with bilateral disease. They found no advantage of the endoscopic method; in particular there was no reduction of scar discomfort in the

References (16)

M.P. Nancollas et al.
Long-term results of carpal tunnel release
J Hand Surg
(1995)
W. Kluge et al.
Late complications after open carpal tunnel decompression
J Hand Surg
(1996)
H.S. Matloub et al.
The detailed anatomy of the palmar cutaneous nerves and its clinical implications
J Hand Surg
(1998)
A. Biyani et al.
Distribution of nerve fibres in the standard incision for the carpal tunnel decompression
J Hand Surg
(1996)
U. Ahcan et al.
Surgical technique to reduce scar discomfort after carpal tunnel surgery
J Hand Surg
(2002)
A. Gulati et al.
Carpal tunnel decompressionThe impact of tourniquet, anaesthesia type, and operating team on patient satisfaction scores
Br J Plast Surg
(2005)
A.C. Macey et al.
Outcomes of hand surgery
J Hand Surg
(1995)
J.L. Hobby et al.
Validity and responsiveness of the patient evaluation measure as an outcome measure for carpal tunnel syndrome
J Hand Surg
(2005)

There are more references available in the full text version of this article.

Cited by (35)

Pillar Pain After Minimally Invasive and Standard Open Carpal Tunnel Release: A Systematic Review and Meta-analysis
2024, Journal of Hand Surgery Global Online
Pillar pain is a recognized postoperative complication of carpal tunnel release (CTR). Minimally invasive and alternative surgical techniques can theoretically prevent pillar pain, and the aim of this review was to compare the incidence of pillar pain after standard open CTR and alternative surgical techniques.
MEDLINE, Embase, and Scopus databases were thoroughly searched. Randomized controlled trials comparing minimally invasive surgical techniques to standard open CTR were identified. Data, including surgical technique, number of hands, incidence of pillar pain, and follow-up intervals, were extracted. Odds ratios (OR) were expressed as pillar pain incidence in the intervention group relative to standard open CTR.
There were 12 studies included. No statistically significant differences were noted among endoscopic (OR = 0.53, P = .20), flexor retinaculum lengthening (OR = 1.00, P = 1.00), short incision (OR = 0.41, P = .07) or illuminated knife techniques (OR = 0.18, P = .16). There was a statistically significant decrease in pillar pain after minimally invasive CTR (OR = 0.41, 95% confidence interval 0.20–0.86, I² = 0%, P = .02) between 3- and 6-months follow-up; however, analyses at all other follow-up periods failed to reach statistical significance.
Although our findings suggest that standard open CTR may be associated with an increased duration of pillar pain between 3 and 6 months postoperatively, our results suggest that minimally invasive CTR techniques do not affect either the initial development or persistence of pillar pain.
Our results illustrate the natural history of pillar pain with the majority of cases resolving after 6 months, highlighting the utility of symptomatic and conservative treatments and patient education in the management of pillar pain.
Effectiveness of Platelet-Rich Plasma Injections for Nonsurgical Management of Carpal Tunnel Syndrome: A Systematic Review and Meta-analysis of Randomized Controlled Trials
2020, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
Mild-moderate CTS symptoms typically consist of tingling or paresthesia with limited intermittent pain only with provocation or repetitive activities.6-8,35 In addition, previous studies of carpal tunnel release demonstrate that those with the milder disease do not demonstrate as significant or reliable improvements in VAS.12,36-38 As such, those with comparatively severe disease as included in the Wu et al25 study demonstrated significant improvements in VAS while all other studies with minimal to mild disease demonstrated no significant improvement.
To systematically review and evaluate the efficacy and complication profile of platelet-rich plasma (PRP) injection into the carpal tunnel for management of carpal tunnel syndrome (CTS).
PubMed, MEDLINE, SCOPUS, EMBASE, Google Scholar, Cochrane Central Register of Controlled Trials, and Web of Sciences (from inception to January 1, 2019).
Controlled trials addressing PRP for CTS.
Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. The outcomes of interest were the visual analog score (VAS) for pain and the Boston Carpal Tunnel Questionnaire (BCTQ), including the subscales of the symptom severity scale (SSS) and the Functional Status Scale (FSS). Other reported outcome measures and complications were analyzed descriptively.
Four randomized controlled studies satisfied the inclusion criteria and analyzed a total of 191 cases with a final follow-up of either 3 or 6 months. Control groups included splinting in 2 studies, corticosteroid injection in 1 study, and saline injection in 1 study. There was a statistically and clinically significant improvement in the BCTQ (standardized mean difference=-2.06; 95% confidence interval [CI], -3.41 to -0.70; P=.003) between groups. Subgroup analysis showed significant improvement in SSS (standardized mean difference=-1.95; 95% CI, -3.65 to -0.25; P=.02) but not for FSS (standardized mean difference=-2.19; 95% CI, -4.77 to 0.40; P=.10). There was a similar improvement in VAS and nerve conduction studies in those receiving PRP compared to controls. Complication rate in the included studies was low with 4 of 97 participants receiving PRP injections experiencing transient pruritis, burning, or tingling.
PRP represents a promising therapy for patients with mild to moderate CTS; however, included studies were limited as follow-up was short, the studies included patients that were heterogeneous, and the number of included studies was low. Further investigation is necessary to determine the true efficacy and effect of PRP and to better delineate the long-term results in patients with CTS.
Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome—A Systematic Review
2018, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
There is conflicting evidence for the effectiveness of modified carpal tunnel release compared with standard open tunnel release in the short-term, midterm, and long-term. The high-quality RCT37 (n=84) found no significant differences in favor of carpal tunnel decompression by using a technique to preserve the superficial nerve branches compared with a standard technique, on scar pain scores or the second part of the Patient Evaluation Measure score at 3 and 6 months' follow-up. Forward et al40 (n=111, low quality) compared open carpal tunnel release with preservation of the parietal layer of the ulnar bursa to division of the ulnar bursa.
To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome (CTS).
The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.
Two reviewers independently applied the inclusion criteria to select potential studies.
Two reviewers independently extracted the data and assessed the methodologic quality.
A best-evidence synthesis was performed to summarize the results. Four systematic reviews and 33 RCTs were included. Surgery versus nonsurgical interventions, timing of surgery, and various surgical techniques and postoperative interventions were studied. Corticosteroid injection was more effective than surgery (strong evidence, short-term). Surgery was more effective than splinting or anti-inflammatory drugs plus hand therapy (moderate evidence, midterm and long-term). Manual therapy was more effective than surgical treatment (moderate evidence, short-term and midterm). Within surgery, corticosteroid irrigation of the median nerve before skin closure as additive to CTS release or the direct vision plus tunneling technique was more effective than standard open CTS release (moderate evidence, short-term). Furthermore, short was more effective than long bulky dressings, and a sensory retraining program was more effective than no program after surgery (moderate evidence, short-term). For all other interventions only conflicting, limited, or no evidence was found.
Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short-term, midterm, and/or long-term to treat CTS. However there is strong evidence that a local corticosteroid injection is more effective than surgery in the short-term, and moderate evidence that manual therapy is more effective than surgery in the short-term and midterm. There is no unequivocal evidence that suggests one surgical treatment is more effective than the other. Postsurgical, a short- (2-3 days) favored a long-duration (9-14 days) bulky dressing and a sensory retraining program seems to be more effective than no program in short-term. More research regarding the optimal timing of surgery for CTS is needed.
Carpal tunnel syndrome - Part II (treatment)
2014, Revista Brasileira de Ortopedia
Os tratamentos nas formas não deficitárias da síndrome do túnel do carpo (SCC) são a infiltração de corticoide e/ou uma órtese de imobilização noturna. O tratamento cirúrgico, que compreende a secção do retináculo dos flexores (retinaculotomia), é indicado em caso de resistência ao tratamento conservador nas formas deficitárias ou, mais frequentemente, nas formas agudas. Nas técnicas minimamente invasivas (endoscópica e miniopen), independentemente de a curva de aprendizado ser mais longa, parece que a recuperação funcional é mais precoce em relação à cirurgia clássica, mas com os resultados em longo prazo idênticos. A escolha depende do cirurgião, do paciente, da gravidade, da etiologia e da disponibilidade do material. Os resultados são próximos de 90% de casos satisfatórios. A recuperação da força necessita de quatro a seis meses após a regressão das dores do tipo dor do pilar (pillar pain). Essa cirurgia tem a reputação de ser benigna e apresenta de 0,2% a 0,5% de complicações.
The treatments for non‐deficit forms of carpal tunnel syndrome (CTS) are corticoid infiltration and/or a nighttime immobilization brace. Surgical treatment, which includes sectioning the retinaculum of the flexors (retinaculotomy), is indicated in cases of resistance to conservative treatment in deficit forms or, more frequently, in acute forms. In minimally invasive techniques (endoscopy and mini‐open), and even though the learning curve is longer, it seems that functional recovery occurs earlier than in the classical surgery, but with identical long‐term results. The choice depends on the surgeon, patient, severity, etiology and availability of material. The results are satisfactory in close to 90% of the cases. Recovery of strength requires four to six months after regression of the pain of pillar pain type. This surgery has the reputation of being benign and has a complication rate of 0.2% to 0.5%.
Carpal tunnel syndrome
2014, Chirurgie de la Main
Citation Excerpt :
The palmar fascia is then either incised or retracted laterally. Subcutaneous dissection to preserve the sensory branches may create postoperative pain and has not been proven superior to a direct incision of the FR [74]. Hemostasis using bipolar coagulation is performed if needed.
Carpal tunnel syndrome is the commonest entrapment neuropathy and is due to combined compression and traction on the median nerve at the wrist. It is often idiopathic. Although spontaneous resolution is possible, the usual natural evolution is slow progression. Diagnosis is mainly clinical depending on symptoms and provocative tests. An electromyogram is recommended preoperatively and in cases of work-related disease. Medical treatment is indicated early on or in cases with no deficit and consists of steroid injection in the canal or a night splint in neutral wrist position. Surgical treatment is by section of the flexor retinaculum and is indicated in resistance to medical treatment, in deficit or acute cases. Mini-invasive techniques such as endoscopic and mini-open approaches to carpal tunnel release with higher learning curves are justified by the shorter functional recovery time compared to classical surgery, but with identical long-term results. The choice depends on the surgeon's preference, patient information, stage of severity, etiology and availability of material. Results are satisfactory in 90% of cases. Nerve recovery depends on the stage of severity as well as general patient factors. Recovery of force takes about 2–3 months after the disappearance of ‘pillar pain’. This operation has a benign reputation with a 0.2–0.5% reported neurovascular complication rate.
Le syndrome du canal carpien, le plus fréquent des syndromes canalaires, est dû à des mécanismes combinés de compression et traction du nerf médian au poignet. Il est le plus souvent idiopathique. Bien que des régressions spontanées soient possibles, une aggravation lente est observée le plus souvent. Le diagnostic est avant tout clinique, reposant sur les symptômes et les tests de provocation. Un examen électroneuromyographique est recommandé en période préopératoire ou en cas de maladie professionnelle. Le traitement médical est indiqué de première intention dans les formes non déficitaires et repose sur l’infiltration intracanalaire de corticoïdes et/ou une orthèse d’immobilisation nocturne en rectitude du poignet. Le traitement chirurgical qui comprend la section du rétinaculum des fléchisseurs, est licite en cas de résistance au traitement médical, dans les formes déficitaires ou dans les formes aiguës. Les techniques mini-invasives (endoscopie, mini-open) aux courbes d’apprentissage plus longues semblent créditées d’une récupération fonctionnelle plus précoce par rapport à la chirurgie classique, mais avec des résultats identiques à long terme. Le choix dépend du chirurgien, de l’information du patient, du stade de gravité, de son étiologie et de la disponibilité du matériel. Les résultats sont satisfaisants dans près de 90 % des cas. Rapidité et importance de la récupération neurologique dépendent du stade de gravité et du terrain. La récupération de force demande deux ou trois mois après régression des douleurs de type pillar pain. Cette chirurgie à la réputation de bénignité a 0,2 à 0,5 % de complications majeures neurovasculaires.
Comparison of longitudinal open incision and two-incision techniques for carpal tunnel release
2010, Journal of Hand Surgery
This study analyzes the long-term postoperative symptoms and functional outcomes of patients who underwent either traditional open (single-incision) or 2-incision carpal tunnel release (CTR). Because 2-incision CTR preserves the superficial nerves and subcutaneous tissue between the thenar and hypothenar eminences, it may account for fewer postoperative symptoms and improved functional recovery.
A retrospective chart review identified patients who underwent either open or 2-incision CTR for isolated carpal tunnel syndrome between 2005 and 2008 by a single surgeon. Patients with a history of hand trauma or confounding comorbidities were excluded. We mailed a Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire and a Brigham and Women's Carpal Tunnel Questionnaire (BWCTQ) to all eligible participants. Data from the completed questionnaires were analyzed using independent t-tests and Pearson's correlation. Significance was set at p = .05.
A total of 82 patients (106 hands; 27 men and 55 women; mean age, 60.5 y) were eligible to participate. Of these, 51 patients (63 hands; 20 men and 31 women; mean age, 61.1 y) responded (62% response rate). The mean duration of follow-up was 22 months (range, 12–37 mo; SD 7.3 mo). The 2-incision group mean BWCTQ Symptom Severity Scale score (1.13, SD 0.25) was significantly lower than the open group mean Symptom Severity Scale score (1.54, SD 0.70, p = .001). The 2-incision group mean BWCTQ Functional Status Scale score (1.24, SD 0.51) was significantly lower than the open group mean Functional Status Scale score (1.71, SD 0.76, p = .008). The 2-incision group mean DASH score (5.10, SD 12.03) was significantly lower than the open group mean DASH score (16.28, SD 19.98, p = .01).
Patients treated with 2-incision CTR reported statistically significantly less severe long-term postoperative symptoms and improved functional status compared with patients treated with traditional open CTR. Future prospective studies with objective measures are needed to further investigate the difference in outcomes found between these 2 CTR techniques.
Therapeutic III.

View all citing articles on Scopus

: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

View full text

NerveStandard Open Decompression in Carpal Tunnel Syndrome Compared With a Modified Open Technique Preserving the Superficial Skin Nerves: A Prospective Randomized Study

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

Materials and Methods

Results

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Br J Plast Surg

J Hand Surg

J Hand Surg

Nerve
Standard Open Decompression in Carpal Tunnel Syndrome Compared With a Modified Open Technique Preserving the Superficial Skin Nerves: A Prospective Randomized Study