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Re: Carpal tunnel - Are non-operative interventions effectively utilised?

Yes, the poor use of non-operative interventions (as reported in this article) does indeed seem to be the effective use of these interventions that (the authors themselves acknowledge) are not curative but merely delay the curative operation.

On both economic and patient parameters it is more economic to proceed directly with the curative intervention than waste resources and time attempting non-curative interventions that merely delay the procedure and add to the overall cost of the event. Delaying a curative operation may be of benefit in some isolated cases when the inconvenience of the procedure and its recovery are untimely. Non- curative symptom controlling interventions can also be of use whilst waiting for the procedure. However, the symptom controlling interventions can lead to delay in the performance of the curative operation possibly resulting in worse outcomes. There is a correlation between severity and chronicity of symptoms with poorer outcome (Hobby et al, Townshend et al, Bland et al.) As carpal tunnel syndrome progresses the annoying symptoms of pain and paraesthesia may actually dissipate leading the sufferer to believe their condition is improving whilst unbeknown to them the severity of their condition is worsening, their obvious symptoms being insidiously replaced by the less obvious loss of sensibility and motion. Intervention at this later stage is less likely to result in complete cure.

In carpal tunnel syndrome, as in most diseases the intervention likely to cure the condition should be implemented without unnecessary costly steps or delay.

Hobby JL, Venkatesh R, Motkur P. The effect of age and gender upon symptoms and surgical outcomes in carpal tunnel syndrome. J Hand Surg [Br]. 2005 Dec;30(6):599-604. Epub 2005 Sep 6.

Townshend DN, Taylor PK, Gwynne-Jones DP. The outcome of carpal tunnel decompression in elderly patients. J Hand Surg [Am]. 2005 May;30(3):500-5.

Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve. 2001 Jul;24(7):935-40.

Send letter to journal:
Re: Re: Carpal tunnel - Are non-operative interventions effectively utilised?

The authors thank Henke Giele for his contribution to this discussion. We are pleased to see that he allows for some delaying of a curative operation in isolated cases when the inconvenience of the procedure and its recovery are untimely. He goes on to state that there is a correlation between severity of post-operative complaints and chronicity of symptoms and cites three papers that come to that conclusion. However this is not a situation where the literature offers an unambiguous view. There are other publications, which have come to the contrary opinion (Yu et al and Choi and Ahn). We have also looked at the relationship between the duration and severity of symptoms and outcome after carpal tunnel decompression (using the same patients that were studied in the Primary Care Management paper)(Burke et al). Symptom duration corrected for gender was not associated with Levine-Katz symptom severity, Levine-Katz functional status or changes in these scores from the pre-treatment to six months follow-up evaluations.

We feel it is overly simplistic to classify all patients with Carpal Tunnel Syndrome as in need of operative intervention. Mr Giele is undoubtedly aware of the extended spectrum of symptom severity in these cases and not all patients will consider the symptoms they are experiencing justify the need to consider surgery. Over and above that there is the characteristic remitting nature of the condition where patients not uncommonly go through periods of resolution or easing of symptoms for several months. The issue from our point of view is that of patient choice. There are conservative methods of treating Carpal Tunnel Syndrome, which are known to be effective and are underused. We prefer the strategy of giving the patients the facts about their condition and all treatment modalities that might benefit them, and allow the patient to decide if they wish to explore the non-operative interventions. No operative procedure is without its risks and the complications arising from the use of non-operative methods in cases of mild to moderate Carpal Tunnel Syndrome are slight. We remain of the view that the correlation between extended duration of symptoms and poor outcome is not proven and Mr Giele’s view that virtually all patients with Carpal Tunnel Syndrome require expeditious decompression is not justified.

Yours sincerely

Frank Burke & Shaw Wilgis

Yu GZ Firrell JC Tsai TM. Pre-operative factors and treatment outcome following carpal tunnel release. J Hand Surg 1992:17B:646-650

Choi SJ Ahn DS. Correlation of clinical history and electrodiagnostic abnormalities with outcome after surgery for Carpal Tunnel Syndrome. Plast Reconstr Surg 1998;102:2374-2380

Burke FD Wilgis EFS Dubin NH Bradley MJ Sinha S: Relationship between the duration and severity of symptoms and the outcome of carpal tunnel surgery. J Hand Surg 2006: 31A:1478-1482