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Michael  S.  Bednar,  M.D.Chief,  Hand  SurgeryProfessor,   Dept  of   Orthopaedic  Surgery  and  RehabLoyola   University  -­‐ Chicago

Disclosure� No  conflicts   for   this  talk

Carpal  Tunnel  Syndrome� AKA

� Corporal  tunnel  syndrome� Carpool  tunnel  syndrome� Copper  tunnel  syndrome

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Carpal  Tunnel  Syndrome� New  York  Times  Health  Guide   – 7/2013

� Every  year  more  than  500,000   people   in  the  US  undergo  surgeries   for  carpal   tunnel  syndrome.  Surgery  for  CTS   is  among  the  most  common  hand  surgeries.  

Carpal  Tunnel  Syndrome� Since  1996,   there  have  been  4101  publications   in  

English  cited  in  Ovid  on  CTS� Evidence  based  medicine  

� gathering  the  results  from  the  highest  level  of  research  in  the  peer  review  literature  

� form  consensus  about  how  to  treat  a  condition� Cochrane  

� independent  group  � gathers  and  summarizes  the  best  evidence  from  research  

to  help  health  care  providers  and  patients  make  informed  choices  about  treatment

Carpal   Tunnel   Syndrome   –Conservative   Care� Splinting

� Cochrane  Review  7/2012� 19  randomised or  quasi-­‐randomised controlled   trials   with   1190  

participants  � Limited  evidence  that   a  splint  worn   at  night   is  more  effective  than  no  treatment   in  the  short   term

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Carpal  Tunnel  Syndrome  –Conservative  Care� Splinting

� Cochrane  Review  7/2012� Insufficient  evidence  regarding  the  effectiveness  and  safety  of  one  splint  design  or  wearing  regimen  over  others

Carpal  Tunnel  Syndrome  –Conservative  Care� Ergonomic  Equipment  

and  Positioning

Carpal   Tunnel   Syndrome   –Conservative   Care� Ergonomic  Equipment  and  Positioning

� Cochrane  Review  1/2012� Only  two  studies  involving  105  participants� There  is  insufficient  evidence  from  randomized  controlled  trials  to  determine  whether  ergonomic  positioning  or  equipment  is  beneficial  or  harmful  for  treating  carpal  tunnel  syndrome

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Carpal   Tunnel   Syndrome   –Conservative   Care

Carpal  Tunnel  Syndrome  –Conservative  Care� Exercise  and  Mobilization  

Interventions

Carpal   Tunnel   Syndrome   –Conservative   Care� Exercise  and  Mobilization   Interventions

� Cochrane  Review  6/2012� Based  on  the  16  studies  identified,  there  is  limited  and  very  low  quality  evidence of  benefit  for  all  of  a  diverse  collection  of  exercise  and  mobilization  interventions  in  treating  people  with  carpal  tunnel  syndrome

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Carpal   Tunnel   Syndrome   –Conservative   Care� Therapeutic  Ultrasound

� Cochrane  Review  3/2013� 11  randomised  controlled  trials  including  443  

participants  � There  is  only  poor  quality  evidence  from  very  limited  data  to  suggest  that  therapeutic  ultrasound  may  be  more  effective  than  placebo  for  either  short-­‐ or  long-­‐term  symptom  improvement  in  people  with  CTS  

Carpal   Tunnel   Syndrome   –Conservative   Care� Local   corticosteroid   injection  – What  it  does

� Cochrane  Review  4/2007� 12  studies  with  671  participants� Greater  clinical  improvement  in  symptoms  one  month  after  injection  compared  to  placebo

� Significant  symptom  relief  beyond  one  month  has  not  been  demonstrated

� Significantly  greater  clinical  improvement  than  oral  corticosteroid  for  up  to  three  months.  

Carpal   Tunnel   Syndrome   –Conservative   Care� Local   corticosteroid   injection  – What  it  does  not  do

� Cochrane  Review  4/2007� Does  not  significantly  improve  clinical  outcome  compared  to  either  anti-­‐inflammatory  treatment  and  splinting  after  eight  weeks  

� Two  local  corticosteroid  injections  do  not  provide  significant   added  clinical  benefit  compared  to  one  injection

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Carpal   Tunnel   Syndrome   –Conservative   Care� Local   corticosteroid   injection

� Blazer,  et  al.    JBJS  2015� 54  mild  to  moderate  symptomatic  wrists  in  49  patients� Single  injection  gave  symptom  relief  in  79%  of  patients  

at  6  weeks� Symptom  relief  maintained  at  12  months  in  31%  of  

patients� Higher  rate  of  symptom  recurrence  in  diabetic  patients.

Carpal  Tunnel  Syndrome  –Conservative  Care� Local   corticosteroid   injection� Who  get  one  from  me?

� Last  trimester  of  pregnancy� Acute  flexor  tendon  inflammation� Patients  awaiting  surgery� Diabetic  patients  with  both  compressive  neuropathy  

and  polyneuropathy� Patients  with  recurrent  CTS

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Carpal  Tunnel  Syndrome  � Surgical   versus  Conservative  Treatment

� Cochrane  Review  8/2008� Four  randomized  controlled  trials  involving  317  

participants  � Significant  proportion  of  people  treated  medically  will  require  surgery

� Surgery  relieves  symptoms  significantly  better  than  splinting

� Risk  of  re-­‐operation  in  surgically  treated  people  is  low� Unknown  whether  this  conclusion  applies  to  people  with  mild  symptoms

Carpal   Tunnel   Syndrome   –Surgical  Treatment� Endoscopic   versus  Open  Release

� Cochrane  Review  1/2014� 28  studies  involving  2586  participants� With  support  from  low  quality  evidence  only,  OCTR  and  ECTR  are  about  as  effective  as  each  other  in  relieving  symptoms  and  improving  hand  function  in  CTS

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Carpal   Tunnel   Syndrome   –Surgical  Treatment� Endoscopic   versus  Open  Release,  <3  month  F/U

� Cochrane  Review  1/2014� Pain  scores  favored  ECTR  over  conventional  OCTR   in  two  studies

� No  difference  was  found  in  numbness  � Grip  strength  was  increased  after  ECTR  when  compared  with  OCTR  by  4  kg,  which  is  probably  not  clinically  significant

Carpal   Tunnel   Syndrome   –Surgical  Treatment� Endoscopic   versus  Open  Release,  >3  month  F/U

� Cochrane  Review  1/2014� No  significant  difference  in  overall  improvement  between  ECTR  and  OCTR  

� ECTR  and  OCTR  did  not  differ  in  the  long  term  in  pain  or  in  numbness  

� Grip  strength  testing  favored  ECTR  by  11  kg  � Patients  treated  with  ECTR  returned  to  work  or  daily  activities  eight  days  earlier  than  participants  treated  with  OCTR

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Carpal   Tunnel   Syndrome   –Surgical  Treatment� Endoscopic   versus  Open  Release,  >3  month  F/U

� Cochrane  Review  1/2014� Both  treatments  were  equally  safe  with  only  a  few  reports  of  major  complications  (mainly  with  complex  regional  pain  syndrome)

Carpal   Tunnel   Syndrome   –Surgical  Treatment  Complications� Endoscopic   versus  Open  Release,  >3  month  F/U

� Cochrane  Review  1/2014� ECTR  resulted  in  a  significantly  lower  rate  of  minor  complications,  corresponding  to  a  45%  relative  drop  in  the  probability  of  complications  

� ECTR  more  frequently  resulted  in  transient  nerve  problems  (ie,  neurapraxia,  numbness,  and  paresthesia),  while  OCTR  had  more  wound  problems  (ie,  infection,  hypertrophic  scarring,  and  scar  tenderness)

Subq  nerve  branches� Martin,   Seiler,   Lesesne

� The  Cutaneous  Innervations  of  the  Palm:    An  Anatomic  Study  of  the  Ulnar  and  Median  Nerves

� J  Hand  Surg  21A,  634-­‐638,  1996� 25  cadaveric  hands� Dissected  cutaneous  branches  of  median  and  ulnar  nerves

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Subq  nerve  branches� Martin,  Seiler,  Lesesne

� The  Cutaneous   Innervations   of   the  Palm:    An  Anatomic   Study   of  the  Ulnar   and   Median   Nerves

� J  Hand   Surg   21A,  634-­‐638,  1996

� Median  Nerve� In  3  hands,  PCBMN  or  

branches  crossed  incision

Subq  nerve  branches� Martin,  Seiler,  Lesesne

� The  Cutaneous   Innervations   of   the  Palm:    An  Anatomic   Study   of  the  Ulnar   and   Median   Nerves

� J  Hand   Surg   21A,  634-­‐638,  1996

� Ulnar  Nerve  branches  jeopardized  by  incision� PCBUN  – 2

Subq  nerve  branches� Martin,  Seiler,  Lesesne

� The  Cutaneous   Innervations   of   the  Palm:    An  Anatomic   Study   of  the  Ulnar   and   Median   Nerves

� J  Hand   Surg   21A,  634-­‐638,  1996

� Ulnar  Nerve  branches  jeopardized  by  incision� PCBUN  – 2� Nerve  of  Henle  – 6

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Subq  nerve  branches� Martin,  Seiler,  Lesesne

� The  Cutaneous   Innervations  of  the   Palm:    An  Anatomic  Study   of  the   Ulnar   and  Median   Nerves

� J  Hand   Surg   21A,  634-­‐638,  1996

� Ulnar  Nerve  branches  jeopardized  by  incision� PCBUN  – 2� Nerve  of  Henle  – 6� Transverse  palmar  

cutaneous  branches  –11

Subq  nerve  branches� Martin,  Seiler,  Lesesne

� The  Cutaneous   Innervations   of   the  Palm:    An  Anatomic   Study   of  the  Ulnar   and   Median   Nerves

� J  Hand   Surg   21A,  634-­‐638,  1996

� Conclusion� 16/25  specimens  had  cutaneous  

nerves  transected  by  CTR

Carpal   Tunnel   Syndrome   –Surgical  Treatment� Rehabilitation   following   Carpal   Tunnel  Release

� Cochrane  Review  6/2013� 20  trials  with  a  total  of  1445  participants� Studies  were  very  low  in  quality� One  small  high  quality  trial  studied  a  desensitization  

program  compared  to  standard  treatment  and  revealed  no  statistically  significant  functional  benefit based  on  the  Boston  Carpal  Tunnel  Questionnaire  (BCTQ)

� The  decision  to  provide  rehabilitation  following  CTS  surgery  should  be  based  on  the  clinician's  expertise,  the  patient's  preferences  and  the  context  of  the  rehabilitation  environment

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Cubital  Tunnel  Syndrome  –Surgical

Cubital  Tunnel  Syndrome  –Surgical

Cubital  Tunnel  Syndrome  –Surgical

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Cubital  Tunnel  Syndrome  –Surgical� Cochrane  Review  7/2012

� Three  randomized  clinical  trials  of 131  participants  were  treated  by  simple  decompression  and  130  participants  were  treated  by  transposition  of  the  nerve  (submuscular  or  subcutaneous  transposition)

� No  significant  difference  between  simple  decompression  and  transposition  of   the  ulnar  nerve  (subcutaneous  or  submuscular)  in  postoperative  clinical  and  neurophysiological  improvement

Cubital  Tunnel  Syndrome  –Surgical� Cochrane  Review  7/2012

� One  trial  of  47  participants  compared  medial  epicondylectomy  with  anterior  transposition  

� No  difference  in  clinical  and  neurophysiological  outcomes.  

� Conclusion:    Available  evidence  is  not  sufficient  to  identify  the  best  treatment  of  ulnar  neuropathy  at  the  elbow,  on  the  basis  of  clinical,  neurophysiological  and  imaging  characteristics

Cubital  Tunnel  Syndrome  –Surgical    NOT  SO  FAST� Predictors  of   surgical   revision   after  in   situ  

decompression   of   the  ulnar  nerve� Krogue,  Aleem  ,Osie,  Goldfarb,  Calfee.    J  Shoulder  

Elbow  2015� Revision  rate  after  in  situ  cubital  tunnel  release  19%  (44  

of   231)� Indications

� Numbness/tingling  (72.7%)� Pain  at  elbow  (59.1%)

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Cubital  Tunnel  Syndrome  –Surgical    NOT  SO  FAST� Predictors  of   surgical   revision   after  in   situ  

decompression   of   the  ulnar  nerve� Krogue,  Aleem  ,Osie,  Goldfarb,  Calfee.    J  Shoulder  

Elbow  2015� Predictors  of  revision  surgery

� History  of  prior  elbow  fracture  or  dislocation� McGowan  stage  I  disease

� Hypothesis� Persistent  tension  on  ulnar  nerve

Conclusions� Carpal   tunnel  syndrome  and  cubital  tunnel  syndrome    

are  commonly  diagnosed  and  treated  conditions� Despite   a  large  volume  of  publications,   the  available  

literature  offers   few  definitive   recommendations  on  treatment

THANK  YOU