Disclosure. Carpal Tunnel Syndrome 11/9/15

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Kory Oliver
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Rehab Loyola University - Chicago Disclosure No conflicts for

1 Michael S. Bednar, M.D. Chief, Hand Surgery Professor, Dept of Orthopaedic Surgery and Rehab Loyola University - Chicago Disclosure No conflicts for this talk Carpal Tunnel Syndrome AKA Corporal tunnel syndrome Carpool tunnel syndrome Copper tunnel syndrome 1

Carpal Tunnel Syndrome New York Times Health Guide 7/2013 Every year more than 500,000 people in the US undergo surgeries for carpal tunnel syndrome.

2 Carpal Tunnel Syndrome New York Times Health Guide 7/2013 Every year more than 500,000 people in the US undergo surgeries for carpal tunnel syndrome. Surgery for CTS is among the most common hand surgeries. Carpal Tunnel Syndrome Since 1996, there have been 4101 publications in English cited in Ovid on CTS Evidence based medicine gathering the results from the highest level of research in the peer review literature form consensus about how to treat a condition Cochrane independent group gathers and summarizes the best evidence from research to help health care providers and patients make informed choices about treatment Splinting Cochrane Review 7/ randomised or quasi- randomis ed controlled trials with 1190 participants Limited evidence that a splint worn at night is more effective than no treatment in the short term 2

Review 1/2012 Only two studies involving 105 participants There is insufficient evidence from randomized controlled

3 Splinting Cochrane Review 7/2012 Insufficient evidence regarding the effectiveness and safety of one splint design or wearing regimen over others Ergonomic Equipment and Positioning Ergonomic Equipment and Positioning Cochrane Review 1/2012 Only two studies involving 105 participants There is insufficient evidence from randomized controlled trials to determine whether ergonomic positioning or equipment is beneficial or harmful for treating carpal tunnel syndrome 3

very low quality evidence of benefit for all of a diverse collection of

4 Exercise and Mobilization Interventions Exercise and Mobilization Interventions Cochrane Review 6/2012 Based on the 16 studies identified, there is limited and very low quality evidence of benefit for all of a diverse collection of exercise and mobilization interventions in treating people with carpal tunnel syndrome 4

5 Therapeutic Ultrasound Cochrane Review 3/ randomised controlled trials including 443 participants There is only poor quality evidence from very limited data to suggest that therapeutic ultrasound may be more effective than placebo for either short- or long- term symptom improvement in people with CTS Local corticosteroid injection What it does Cochrane Review 4/ studies with 671 participants Greater clinical improvement in symptoms one month after injection compared to placebo Significant symptom relief beyond one month has not been demonstrated Significantly greater clinical improvement than oral corticosteroid for up to three months. Local corticosteroid injection What it does not do Cochrane Review 4/2007 Does not significantly improve clinical outcome compared to either anti- inflammatory treatment and splinting after eight weeks Two local corticosteroid injections do not provide significant added clinical benefit compared to one injection 5

6 Local corticosteroid injection Blazer, et al. JBJS mild to moderate symptomatic wrists in 49 patients Single injection gave symptom relief in 79% of patients at 6 weeks Symptom relief maintained at 12 months in 31% of patients Higher rate of symptom recurrence in diabetic patients. Local corticosteroid injection Who get one from me? Last trimester of pregnancy Acute flexor tendon inflammation Patients awaiting surgery Diabetic patients with both compressive neuropathy and polyneuropathy Patients with recurrent CTS 6

Carpal Tunnel Syndrome Surgical versus Conservative Treatment Cochrane Review 8/2008 Four randomized controlled trials involving 317 participants Significant proportion

Unknown whether this conclusion applies to people with mild symptoms Surgical Treatment Endoscopic versus Open Release Cochrane Review 1/2014 28 studies involving 2586

7 Carpal Tunnel Syndrome Surgical versus Conservative Treatment Cochrane Review 8/2008 Four randomized controlled trials involving 317 participants Significant proportion of people treated medically will require surgery Surgery relieves symptoms significantly better than splinting Risk of re- operation in surgically treated people is low Unknown whether this conclusion applies to people with mild symptoms Surgical Treatment Endoscopic versus Open Release Cochrane Review 1/ studies involving 2586 participants With support from low quality evidence only, OCTR and ECTR are about as effective as each other in relieving symptoms and improving hand function in CTS 7

Surgical Treatment Endoscopic versus Open Release, <3 month F/U Cochrane Review 1/2014 Pain scores favored ECTR over conventional OCTR in two studies No difference was found

Release, >3 month F/U Cochrane Review 1/2014 No significant difference in overall improvement between ECTR and OCTR ECTR and OCTR did not differ in the long term in pain or

8 Surgical Treatment Endoscopic versus Open Release, <3 month F/U Cochrane Review 1/2014 Pain scores favored ECTR over conventional OCTR in two studies No difference was found in numbness Grip strength was increased after ECTR when compared with OCTR by 4 kg, which is probably not clinically significant Surgical Treatment Endoscopic versus Open Release, >3 month F/U Cochrane Review 1/2014 No significant difference in overall improvement between ECTR and OCTR ECTR and OCTR did not differ in the long term in pain or in numbness Grip strength testing favored ECTR by 11 kg Patients treated with ECTR returned to work or daily activities eight days earlier than participants treated with OCTR 8

9 Surgical Treatment Endoscopic versus Open Release, >3 month F/U Cochrane Review 1/2014 Both treatments were equally safe with only a few reports of major complications (mainly with complex regional pain syndrome) Surgical Treatment Complications Endoscopic versus Open Release, >3 month F/U Cochrane Review 1/2014 ECTR resulted in a significantly lower rate of minor complications, corresponding to a 45% relative drop in the probability of complications ECTR more frequently resulted in transient nerve problems (ie, neurapraxia, numbness, and paresthesia), while OCTR had more wound problems (ie, infection, hypertrophic scarring, and scar tenderness) Subq nerve branches Martin, Seiler, Lesesne The Cutaneous Innervations of the Palm: An Anatomic Study of the Ulnar and Median Nerves J Hand Surg 21A, , cadaveric hands Dissected cutaneous branches of median and ulnar nerves 9

10 Subq nerve branches Martin, Seiler, Lesesne The Cutaneous Innervations of the Palm: An Anatomic Study of the Ulnar and Median Nerves J Hand Surg 21A, , 1996 Median Nerve In 3 hands, PCBMN or branches crossed incision Subq nerve branches Martin, Seiler, Lesesne The Cutaneous Innervations of the Palm: An Anatomic Study of the Ulnar and Median Nerves J Hand Surg 21A, , 1996 Ulnar Nerve branches jeopardized by incision PCBUN 2 Subq nerve branches Martin, Seiler, Lesesne The Cutaneous Innervations of the Palm: An Anatomic Study of the Ulnar and Median Nerves J Hand Surg 21A, , 1996 Ulnar Nerve branches jeopardized by incision PCBUN 2 Nerve of Henle 6 10

11 Subq nerve branches Martin, Seiler, Lesesne The Cutaneous Innervations of the Palm: An Anatomic Study of the Ulnar and Median Nerves J Hand Surg 21A, , 1996 Ulnar Nerve branches jeopardized by incision PCBUN 2 Nerve of Henle 6 Transverse palmar cutaneous branches 11 Subq nerve branches Martin, Seiler, Lesesne The Cutaneous Innervations of the Palm: An Anatomic Study of the Ulnar and Median Nerves J Hand Surg 21A, , 1996 Conclusion 16/25 specimens had cutaneous nerves transected by CTR Surgical Treatment Rehabilitation following Carpal Tunnel Release Cochrane Review 6/ trials with a total of 1445 participants Studies were very low in quality One small high quality trial studied a desensitization program compared to standard treatment and revealed no statistically significant functional benefit based on the Boston Carpal Tunnel Questionnaire (BCTQ) The decision to provide rehabilitation following CTS surgery should be based on the clinician's expertise, the patient's preferences and the context of the rehabilitation environment 11

12 Cubital Tunnel Syndrome Surgical Cubital Tunnel Syndrome Surgical Cubital Tunnel Syndrome Surgical 12

13 Cubital Tunnel Syndrome Surgical Cochrane Review 7/2012 Three randomized clinical trials of 131 participants were treated by simple decompression and 130 participants were treated by transposition of the nerve (submuscular or subcutaneous transposition) No significant difference between simple decompression and transposition of the ulnar nerve (subcutaneous or submuscular) in postoperative clinical and neurophysiological improvement Cubital Tunnel Syndrome Surgical Cochrane Review 7/2012 One trial of 47 participants compared medial epicondylectomy with anterior transposition No difference in clinical and neurophysiological outcomes. Conclusion: Available evidence is not sufficient to identify the best treatment of ulnar neuropathy at the elbow, on the basis of clinical, neurophysiological and imaging characteristics Cubital Tunnel Syndrome Surgical NOT SO FAST Predictors of surgical revision after in situ decompression of the ulnar nerve Krogue, Aleem,Osie, Goldfarb, Calfee. J Shoulder Elbow 2015 Revision rate after in situ cubital tunnel release 19% (44 of 231) Indications Numbness/tingling (72.7%) Pain at elbow (59.1%) 13

14 Cubital Tunnel Syndrome Surgical NOT SO FAST Predictors of surgical revision after in situ decompression of the ulnar nerve Krogue, Aleem,Osie, Goldfarb, Calfee. J Shoulder Elbow 2015 Predictors of revision surgery History of prior elbow fracture or dislocation McGowan stage I disease Hypothesis Persistent tension on ulnar nerve Conclusions Carpal tunnel syndrome and cubital tunnel syndrome are commonly diagnosed and treated conditions Despite a large volume of publications, the available literature offers few definitive recommendations on treatment THANK YOU 14

PG Session: Power Ortho: Hand & Wrist/ Kyle Bickel, MD, FACS

PG Session: Power Ortho: Hand & Wrist/ Kyle Bickel, MD, FACS WOHC 2012 Hand & Wrist Kyle D. Bickel, M.D., FACS The Hand Center of San Francisco Disclosure Information Western Occupational Health Conference 2012 Kyle D. Bickel, MD, FACS I have no pertinent financial