Surgical treatment options for carpal tunnel syndrome

Scholten, R. J. P. M.; Molen, Aebele Mink van der; Uitdehaag, B. M.J.; Bouter, Lex M.; Vet, Henrica C.W. de

doi:10.1002/14651858.cd003905.pub3

Cited by 177 publications

(123 citation statements)

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“…Surgery can also be done endoscopically; the endoscope is passed through the incision and the transverse carpal ligament is cut from within. Comparisons of endoscopic and open surgical techniques indicate that success and complication rates are broadly similar 112,113 and selection of technique is largely based on surgeon preference. 93,113 Potential complications of surgery include infection, bleeding, nerve injury, scarring, persistence or return of CTS symptoms and, rarely, complex regional pain syndrome.…”

Section: Overview Of Surgical Interventions and Guidelines For Surgerymentioning

confidence: 99%

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Hollingworth

Rooshenas

Busby

et al. 2015

Health Services and Delivery Research

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BackgroundNHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.ObjectivesWe aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.MethodsWe used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.ResultsThere was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.ConclusionsPolicy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Overview Of Surgical Interventions and Guidelines For Surgerymentioning

confidence: 99%

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Hollingworth

Rooshenas

Busby

et al. 2015

Health Services and Delivery Research

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“…Two systematic reviews [44,45] and two randomised studies [46,47] are available, which compare the two procedures. The conclusion is that, at the moment, there is no evidence to support the superiority of ECTR over OCTR in providing short-and long-term symptom improvement and in leading to recovery of normal activities (LOE I, SOR A).…”

Section: Surgical Treatmentmentioning

confidence: 99%

Diagnosis, treatment and follow-up of the carpal tunnel syndrome: a review

et al. 2010

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The carpal tunnel syndrome is a compressive neuropathy with high incidence rates, and its correct diagnosis, treatment and follow-up may lead to significant benefits in healthcare, social and economic terms. In this review, based on systematic review databases and guidelines, we summarise the appropriate indications for the diagnosis, treatment and follow-up, accompanied, whenever possible, by the levels of evidence and strength of recommendations.

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“…Diseases such as diabetes, rheumatoid arthritis, and hypothyroidism, also carry an increased risk of developing CTS [3]. Open carpal tunnel release (OCTR) as treatment for CTS is considered to give good to excellent results for the majority of patients [4].…”

Section: Introductionmentioning

confidence: 99%

Outcome after carpal tunnel release: impact of factors related to metabolic syndrome

Zimmerman

Dahlin

Thomsen

et al. 2016

Journal of Plastic Surgery and Hand Surgery

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165-171. DOI: 10.1080165-171. DOI: 10. /2000656X.2016 General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.• Users may download and print one copy of any publication from the public portal for the purpose of private study or research.• You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. In a retrospective observational study, we evaluated outcome after open carpal tunnel release focusing on factors related to the metabolic syndrome: diabetes, hypertension, obesity (BMI ≥ 30) and statin treatment. MethodsResults from 493 out of 962 patients (531/1044 hands) operated for CTS during 18 months that had filled in QuickDASH questionnaires before and one year after surgery were included in the study. ResultsPatients with diabetes (n=76) p<0.05). The odds of having a change in QuickDASH score <8 was 2.6 times higher in patients with polyneuropathy than in patients without polyneuropathy.Patients with hypertension, obesity or statin treatment had a similar improvement after surgery as patients without these factors. ConclusionsPatients with diabetes without neuropathy, as well as patients with hypertension, obesity or statin treatment, and CTS can expect the same effects of open carpal tunnel release as otherwise healthy patients. Patients with diabetic neuropathy and CTS did not experience the 3 same improvement as otherwise healthy patients and should be informed about the risk of an unsatisfactory outcome.Word count abstract: 242

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Surgical treatment options for carpal tunnel syndrome

Cited by 177 publications

References 61 publications

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Diagnosis, treatment and follow-up of the carpal tunnel syndrome: a review

Outcome after carpal tunnel release: impact of factors related to metabolic syndrome

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