While surgery for carpal tunnel syndrome in patients without an indication of severe nerve damage (denervation) provides better outcomes than non-surgical treatment, the clinical relevance of this difference is modest. The findings are reported in an Article in this week's Surgery Special Issue of the Lancet, written by Professor Jeffrey Jarvik, Harborview Medical Center, University of Washington, Seattle, USA, and colleagues.
In this randomised controlled trial, the authors assigned 116 patients, from eight centres, to carpal tunnel surgery (57 patients) or to a well-defined, non-surgical treatment (including hand therapy and ultrasound; 59 patients). The primary outcome was hand function measured by the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) at 12 months, assessed by research personnel unaware of group assignment.
A total of 44 (77%) patients assigned to surgery underwent surgery. At 12 months, 101 (87%) completed follow-up and were analysed (49 of 57 assigned to surgery and 52 of 59 assigned to non-surgical treatment). Analyses showed a significant 12-month adjusted advantage for surgery in both function and symptoms (calculated by proportions of patients having at least 30% improvement in CTSAQ scores for these indicators, and having minimal interference in daily work or housework activities). 46% of surgery patients met all three criteria, compared with 27% of non-surgery patients.
The authors say: "Overall, these data indicate that, in patients with carpal tunnel syndrome without denervation, surgery modestly improves hand function and symptoms by 3 months compared with a multimodality non-surgical treatment regimen, and this benefit is sustained through 1 year. However, some patients allocated to surgery reported persistent symptoms, and 61% of patients allocated to non-surgical treatment avoided surgery altogether. Our study, together with other previous evidence, indicates that surgery is useful for patients with carpal tunnel syndrome."
In an accompanying Comment, Dr Isam Atroshi, Hässleholm and Kristianstad Hospitals, and Lund University, Sweden, and Dr Christina Gummesson, Lund University, Sweden, say: "Future studies should compare the overall costs of surgical and non-surgical treatments, to take into consideration all relevant aspects. Finally, patients' preference is important: faced with the need to wear a splint each night and during daytime for some weeks, some might prefer early surgery while others may prefer partial recovery to potential surgical risk. Nevertheless, patients with carpal tunnel syndrome who do not have satisfactory improvement with non-surgical treatment should be offered surgery."
Professor Jeffrey Jarvik, Harborview Medical Center, Comparative Effectiveness, Cost and Outcomes Research Center, Seattle, USA. T) +1 206-744-3561 E) jarviks@comcast.net Alternative contact Clare Hagarty, Media Relations T) +1 206 685-1323 E) clareh@u.washington.edu
Dr Isam Atroshi, Hässleholm and Kristianstad Hospitals, and Lund University, Sweden. T) +46 443091279 E) Isam.Atroshi@skane.se
For full Article and Comment, see: http://press.thelancet.com/carpal.pdf
Journal
The Lancet