Patients prefer endoscopic over mini-open carpal tunnel release
Endoscopic carpal tunnel release is preferred over mini-open despite similar outcome: a randomized trialClin Orthop Relat Res. 2013 May;471(5):1548-54. doi: 10.1007/s11999-012-2666-z. Epub 2012 Oct 26
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52 patients with bilateral carpal tunnel syndrome were randomized to have endoscopic release performed on one hand and mini-incision on the other. The trial aimed to compare the subjective patient based outcomes between the two procedures. Despite similar Boston Carpal Tunnel Questionnaire (BCTQ) and DASH scores between the two groups after 3 months, 34 preferred endoscopic technique compared to 13 preferring the mini-incision, mostly due to scars and pillar pain.
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
Inclusion / Exclusion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Since non-operative treatments for carpal tunnel syndrome often fail, the condition can be treated either by endoscopic or open (standard or mini-incision) carpal tunnel releases. Endoscopic technique is often favoured, due to lower pain, faster return to work, and fewer infections and hypertrophic scars. However, it also comes with a risk of median nerve injury. Mini-incision is sometimes chosen by surgeons for its simplicity, cost, and lower complication rates. Regardless, patient preference is an important factor; therefore, the study aimed to compare subjective patient-based outcomes and preferences between the two techniques.
What was the principal research question?
Did subjective outcomes and patient preferences after 3 months differ between endoscopic release, performed on one hand, and mini-incision release, performed on the other, in patients with bilateral carpal tunnel syndrome?
What were the important findings?
- At 3 months, the mean BCTQ-S scores improved similarly in both groups; in the endoscopic group from 3.3 (95% CI 3.1 to 3.5) to 1.5 (95% CI 1.4 to 1.6) and in the mini-incision group from 3.3 (95% CI 3.1 to 3.5) to 1.4 (95% CI 1.4 to 1.6) (p>0.05).
- At 3 months, the mean BCTQ-F score similarly improved from 2.8 (95% CI 2.6 to 3.1) to 1.5 (95% CI 1.4 to 1.6) in the endoscopic group and from 3.0 (95% CI 2.6 to 3.0) to 1.7 (95% CI 1.3 to 1.5) in the mini-incision group (p>0.05).
- At 3 months, mean DASH score in the endoscopic group improved from 48.3 (95% CI 43.7 to 52.9) to 11.3 (95% CI 8.6 to 13.9) and in the mini-incision group from 47.8 (95% CI 43.1 to 52.4) to 10.8 (95%CI 8.1 to 13.6) with no differences between two groups (p>0.05)
- No instances of deep wound infections, median nerve injury, and revisions were seen.
- 34 patients preferred endoscopic technique, 13 preferred mini-incision technique, and the rest had no preference. Preference was not affected by occupation, hand dominance, or electrophysiologic test findings (all p>0.05)
- Endoscopic technique was preferred over mini-incision most primarily due to scar and pillar pain, but the proportion of patients was not significant (p = 0.114). However, a significant number of patients disliked endoscopic method because of transient worsening of symptoms (p=0.004)
What should I remember most?
Endoscopic carpal tunnel release and mini-incision carpal tunnel release provided similar subjective outcomes 3 months after surgery. 34 patients preferred endoscopic technique over mini incision mostly due to the scar and pillar pain this is compared to 13 preferring the mini incision technique.
How will this affect the care of my patients?
Since subjective outcomes seem to not differ between endoscopic and mini-incision techniques, the procedure choice remains in the surgeon’s hand, taking the patient's preference into consideration. Studies with larger sample sizes may be considered, to confirm functional benefit and incidence of complications.
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