Predicting surgical intervention in patients presenting with carpal tunnel syndrome in primary care

Abstract

PurposeCarpal tunnel syndrome (CTS) is a symptomatic compression neuropathy of the median nerve. This study investigated the value of candidate prognostic factors (PFs) in predicting carpal tunnel release surgery.Patients and methodsThis is a retrospective cohort study set in the Clinical Practice Research Datalink. Patients ≥18 years presenting with an incident episode of CTS were identified between 1989 and 2013. Candidate PF’s defined in coded electronic patient records were identified following literature review and consultation with clinicians. Time to first carpal tunnel release surgery was the primary end point. A manual backward stepwise selection procedure was used to obtain an optimal prediction model, which included all the significant PFs.ResultsIn total, 91,412 patients were included in the cohort. The following PFs were included in an optimal model (C-statistic: 0.588 [95% CI 0.584–0.592]) for predicting surgical intervention: geographical region; deprivation status; age hazard ratio (HR 1.02 per year, 95% CI 1.01–1.02); obesity (HR 1.23, 95% CI 1.19–1.27); alcohol drinker (HR 1.05, 95% CI 1.00–1.10); smoker (HR 1.06, 95% 1.03–1.10); inflammatory condition (HR 1.13, 95% CI 0.98–1.29); neck condition (HR 1.13, 95% CI 1.03–1.23); and multisite pain (HR 1.10, 95% CI 1.05–1.15). Although not included in the multivariable model, pregnancy (if gender female) within 1 year of the index consultation, reduced the risk of surgery (HR 0.24, 95% CI 0.21–0.28).ConclusionThis study shows that patients who are older and who have comorbidities including other pain conditions are more likely to have surgery, whereas patients presenting with CTS during or within a year of pregnancy are less likely to have surgery. This information can help to inform clinicians and patients about the likely outcome of treatment and to be aware of which patients may be less responsive to primary care interventions.

Effects of diabetes mellitus on the rate of carpal tunnel release in patients with carpal tunnel syndrome

“…However, in our analysis of recent data, the peak surgical rate was observed at or above 70 years. This implies that CTS patients with more severe symptoms get surgery irrespective of age, which is in line with other recent studies 24 , 25 . With regard to residential area, patients in rural areas received more CTR than those in the capital region, which might be related to their occupations, such as agriculture which is strenuous on wrist.…”

Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis

“…11 Although studies have been done in the UK to capture the rate of carpal tunnel syndrome and decompression surgery, to date we have not found a study that reports complication rates including reoperation and other rarer complications in a general population. 2,5,13 We found that fewer men than women undergo primary carpal tunnel decompression, but they have an increased incidence of reoperation and serious local complications. There could be a variety of reasons for this increased incidence, but we postulate that it could be because of surgery being more technically difficult in a larger hand as there is a greater amount of subcutaneous tissue in the operative field, reducing surgical exposure of the transverse carpal ligament.…”

“… 11 Although studies have been done in the UK to capture the rate of carpal tunnel syndrome and decompression surgery, to date we have not found a study that reports complication rates including reoperation and other rarer complications in a general population. 2 , 5 , 13 …”

“…Known risk factors for carpal tunnel syndrome were also defined using ICD-10 codes including: past medical history of diabetes, hand osteoarthritis, gout, wrist fracture, rheumatoid arthritis, obesity, and hypothyroidism. 5 , 22 Patients were considered to have a past medical history of a condition if a code associated with the condition was found within the hospital episode for carpal tunnel decompression surgery, or any previous hospital episode. Index of multiple deprivation (a government-generated score of relative deprivation based on geographical location within England), Charlson comorbidity index, and ethnicity were also considered as exposures that might be associated with the incidence of reoperation and adverse events.…”

“…4 Initial management is non-surgical, but many patients require surgery to decompress the carpal tunnel and preserve hand function. 2,5 Carpal tunnel decompression surgery is widely undertaken but poorly evaluated, and estimates of complication rates vary widely. [6][7][8] Results highlighted by the Cochrane collaboration have shown that less than 3000 hands have ever been included in any randomised clinical trial involving carpal tunnel surgery, with the majority of trials exploring the role of endoscopic surgery, a procedure that is rarely done in the UK.…”