Endoscopic Release for Severe Carpal Tunnel Syndrome in Octogenarians Yasunori Hattori, MD, PhD, Kazuteru Doi, MD, PhD, Satomi Koide, MD, Sotetsu Sakamoto, MD
Purpose To investigate the clinical outcomes of endoscopic carpal tunnel release for severe carpal tunnel syndrome in octogenarians compared with a younger cohort. Methods Fifty-ﬁve hands in 48 patients were enrolled in this study. There were 27 hands in 24 octogenarians and 28 hands in 24 patients in a younger group with average ages of 83 and 60 years, respectively. Postoperative follow-ups were 8.5 and 7.2 months, respectively. Clinical evaluation included documentation of subjective symptoms and Semmes-Weinstein testing before surgery, 3 months after surgery, and at ﬁnal follow-up. Symptom severity and function outcomes scores and compound muscle action potential of abductor pollicis brevis as an electrophysiological assessment were evaluated before surgery and at the ﬁnal follow-up. Results Nocturnal pain and paresthesias were improved in all patients. The octogenarians had poorer recovery of Semmes-Weinstein testing score and better improvement of outcomes scores than the younger group. There was no difference of the results in postoperative electrophysiological improvement between the groups. Conclusions Endoscopic release for severe carpal tunnel syndrome relieved symptoms and improved activities of daily living in octogenarians. (J Hand Surg Am. 2014;39(12):2448e2453. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic III. Key words Carpal tunnel syndrome, endoscopic carpal tunnel release, octogenarian.
is the most common compression neuropathy of the upper extremity. Although efﬁcacy of carpal tunnel release has been studied and well established in the general population, its efﬁcacy in elderly patients remains uncertain. Authors have suggested that even though the improvement following carpal tunnel release is not as great as with a younger population, carpal tunnel release still offers meaningful beneﬁt in ARPAL TUNNEL SYNDROME (CTS)
From the Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Ogori, Yamaguchi, Japan. Received for publication June 11, 2014; accepted in revised form September 9, 2014. No beneﬁts in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Yasunori Hattori, MD, PhD, Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3, Shimogo, Ogori, Yamaguchi-City, Yamaguchi-Prefecture, 754-0002, Japan; e-mail: [email protected]
Ó 2014 ASSH
Published by Elsevier, Inc. All rights reserved.
elderly patients with CTS.1e7 However, these studies did not compare their outcomes with other age groups.1e7 Contrary to these reports, several authors compared clinical outcome after carpal tunnel release between younger and older patients and demonstrated less favorable outcome in elderly patients.8e11 However, in these studies, preoperative neurophysiological status and clinical symptoms of CTS were not uniform between the groups.8e11 Thus, these studies did not provide a direct comparison of clinical outcome after carpal tunnel release between younger and elderly patients. The purpose of this study was to investigate and compare the clinical outcomes of endoscopic carpal tunnel release (ECTR) for electrophysiologically diagnosed severe CTS in octogenarians with those of a younger cohort. We hypothesized that octogenarians having ECTR for severe CTS would have symptom relief and improved activities of daily living.
ECTR FOR SEVERE CTS IN OCTOGENARIANS
MATERIALS AND METHODS Patients This study was undertaken in conformity with the Declaration of Helsinki after approval of our institutional review board. Written informed consent was obtained from each patient. CTS was diagnosed with physical examination and electrophysiological assessment. We performed a retrospective comparative study of outcomes following an ECTR for severe CTS between octogenarians (octogenarian group) and patients age 55 to 64 years (younger group). The primary inclusion criteria were patients with severe CTS as measured by electrophysiological study who then underwent an ECTR. Compound muscle action potential (CMAP) from the abductor pollicis brevis (APB) was investigated in all patients before surgery. The APBCMAP was recorded with surface electrodes by supramaximal stimulation of the median nerve at the wrist.12 Distal latency was measured from the stimulus artifact to the onset of the potential. Amplitude was measured from the baseline to the negative peak of the potential. Severe CTS was categorized as an undetectable or prolonged distal motor latency of APBCMAP (> 7.0 ms) according to the classiﬁcation of Choi and Ahn.13 The minimum postoperative followup period was 6 months. Exclusion criteria included cognitive difﬁculties that precluded the ability to complete a self-administered questionnaire, insulindependent diabetes, thyroid disease, rheumatoid arthritis, symptomatic cervical radiculopathy, previous carpal tunnel release, cubital tunnel syndrome, symptomatic thumb basal joint arthritis, previous wrist fracture, and previous surgery on the hand. We surgically treated 679 consecutive hands with idiopathic CTS between 2007 and 2013. Among them, 48 patients (55 hands) met these criteria and were enrolled in this study. There were 27 hands in 24 patients in the octogenarian group and 28 hands in 24 patients in younger group. Patient demography is summarized in Table 1. In all hands, an ECTR with 2-portal technique was performed under local anesthesia with a pneumatic tourniquet.14 A sterile bulky dressing without orthosis was applied after surgery. The following day, the patients started gentle ﬁnger and wrist motion exercises. Two weeks after surgery, more vigorous exercises were initiated and scar massage was added. Assessment Clinical evaluation was performed before surgery, 3 months after surgery, and at ﬁnal follow-up. During J Hand Surg Am.
Patients’ Demographic Data Octogenarian
Patients (n, hands)
Younger 24 (28%)
Age at time of surgery (y) 83 3
Male, 3; female, 21
Male, 5; female, 19
Dominant hand (n)
Follow-up periods (mo)
Hands with diminished pinch function (n)
each evaluation, the following parameters were assessed. All patients were reviewed directly by a certiﬁed hand therapist in our hospital who had not been primarily involved in the patients’ management. We asked patients about nocturnal pain and paresthesias in the median nerve distribution. Sensory thresholds in the middle ﬁnger pulp were determined using Semmes-Weinstein monoﬁlaments measuring 0.08, 0.22, 2.4, and 279 g. The lowest ﬁlament force detected reliably was recorded. Patient-reported outcome was measured using the Japanese Society for Surgery of the Hand version of Carpal Tunnel Syndrome Instrument (CTSI)15 before surgery, and at the ﬁnal follow-up. As one of the disease-speciﬁc measures, a self-administered questionnaire for the assessment of severity of symptoms and functional status in CTS, originally described by Levin et al,16 has had several names, for example, CTSI15,17 and the Boston Carpal Tunnel Syndrome Questionnaire.8 CTSI contains a symptom severity subscale and a functional subscale. Symptom severity score is calculated as the mean of the scores for 11 individual items, and function score is calculated as the mean of the scores for 8 items. The questions have multiple-choice responses, scored from 1 point (no symptom) to 5 points (most severe symptom). As an electrophysiological assessment, APBCMAP was evaluated at the ﬁnal follow-up. The responsiveness of instruments including CTSI and amplitude of APB-CMAP was examined by the standardized response mean and effect size. Standardized response mean was calculated as the mean difference between the preoperative and the followup scores divided by the SD of this difference. Effect size was calculated as the mean difference between the preoperative and the follow-up scores divided by the SD of the preoperative scores. The higher these parameters, the greater the responsiveness. The values greater than 0.8 indicated Vol. 39, December 2014
ECTR FOR SEVERE CTS IN OCTOGENARIANS
FIGURE 1: Nocturnal pain and paresthesias at 3 months and ﬁnal follow-up (F/U) in each age group.
large responsiveness, between 0.5 and 0.79 moderate, and less than 0.5 small.17,18 Statistical analysis All results are presented as mean SD and were analyzed using the Fisher exact probability test, Wilcoxon signed-ranks test, or Mann-Whitney U test. The .05 level of probability was established for statistical signiﬁcance. RESULTS The distribution of sex, hand dominance, and postoperative follow-up period did not differ signiﬁcantly between the 2 groups (Table 1). Age averaged 83 years for the octogenarian group and 60 years for the younger group. Before surgery, nocturnal pain was observed in 21 hands (78%) of the octogenarian group and 23 hands (82%) of the younger group. Paresthesias were present in all hands of both groups. Three months after surgery, nocturnal pain and paresthesias improved in most of the hands of the octogenarian group and in all hands of the younger group. Nocturnal pain and paresthesias further improved in both groups at the ﬁnal follow-up (Fig. 1). Monoﬁlament testing showed improvement in both groups following surgery, with the younger group achieving better recovery both at 3 months and at ﬁnal follow-up (Fig. 2). CTSI symptom severity score and function score improved at ﬁnal follow-up in both groups (Fig. 3). J Hand Surg Am.
Improvement of CTSI function score in the octogenarian group was greater than that in the younger group (Table 2). Before surgery, APB-CMAP was undetectable in 11 hands (41%) in the octogenarian group, and 9 hands (32%) in the younger group. At ﬁnal followup, it was undetectable in 9 hands (33%) of the octogenarian group and in 2 hands (7%) of the younger group. APB-CMAP amplitude improved in both groups at ﬁnal follow-up (Fig. 4). There was no difference of the results in postoperative improvement of APB-CMAP amplitude between age groups (Table 2). Except for CTSI function score in the younger group, all other instruments had large responsiveness (> 0.8 of standardized response mean and effect size) (Table 2). There were no complications related to surgery, such as infection, hematoma, tendon laceration, arterial injury, and median nerve injury. No patient required subsequent hand surgery including revision carpal tunnel release by the time of the ﬁnal follow-up. DISCUSSION Wilgis et al11 studied postoperative results of 635 carpal tunnel releases in 490 hands to assess the effect of increasing age on the outcome. Younger patients (< 40 and 41e60 y) obtained better Semmes-Weinstein testing score than the older patients (61e80 and > 80 y). There was no signiﬁcant difference in both scores of CTSI. Porter et al10 prospectively studied 87 patients after open carpal tunnel release. They found Vol. 39, December 2014
ECTR FOR SEVERE CTS IN OCTOGENARIANS
FIGURE 2: Semmes-Weinstein monoﬁlament test at 3 months and ﬁnal follow-up (F/U) in each age group. The purple dotted lines represent the percentage of hands with protective sensation, which was the ability to perceive at least the 2.4-g ﬁlament. pre-op., preoperative.
FIGURE 3: CTSI score at 3 months and ﬁnal follow-up (F/U) in each age group. pre-op., preoperative.
that patients older than 80 years showed more improvement in symptom severity score than those between 61 and 80 years. However, in both of these studies, the preoperative severity of CTS between age groups was not standardized. In order to support the surgical efﬁcacy of ECTR for octogenarian patients, we J Hand Surg Am.
compared clinical outcomes for severe CTS diagnosed by electrophysiological assessment between octogenarians and younger patients. There are some difﬁculties in assessing postoperative outcomes following carpal tunnel release for patients 80 and older compared with younger ones. Vol. 39, December 2014
ECTR FOR SEVERE CTS IN OCTOGENARIANS
Improvement of Each Instrument and Standardized Response Mean and Effect Size Improvement
Standardized Response Mean
CTSI symptom severity score Octogenarian
CTSI function score Octogenarian
P < .05
FIGURE 4: APB-CMAP amplitude at 3 months and ﬁnal followup (F/U) in each age group. pre-op., preoperative.
First, hand function may be inﬂuenced by other conditions that increase with age such as arthritis and muscle weakness. This may be the cause of bias in assessment of postoperative outcomes and may be a factor in the reduced improvement in elderly patients after surgery. Although we excluded the patients with comorbidities to reduce such bias in this study, both preoperative and postoperative CTSI function scores in the octogenarians were signiﬁcantly worse than those in the younger group. Second, the SemmesWeinstein monoﬁlament test is a well-established objective assessment for sensory function. However, this test depends on the patient’s response. Elderly patients may not respond well owing to cognitive difﬁculties. From our results, the octogenarian group had poorer recovery on Semmes-Weinstein testing. J Hand Surg Am.
These outcomes were comparable with those of Wilgis et al.11 The use of this test for sensory assessment in elderly patients may be less reliable compared with its use in younger patients. Although we excluded the patients with apparent cognitive difﬁculties in this study, quantitative evaluation of cognitive function in elderly patients would be essential to obtain more accurate sensory assessment in future studies. The use of a patient-reported outcome measures has become standard to assess the outcome in clinical research.19 Minimal clinically important difference was deﬁned as “the smallest difference that patients perceive as beneﬁcial.”20 Ӧzyürekoglu et al21 found that minimal clinically important difference in CTSI symptom severity score after carpal tunnel steroid injection was 1.04. Recently, Ozer et al22 reported that nondiabetic patients with CTS required 1.45 of symptom severity score and 1.65 of function score improvement, respectively, to be satisﬁed at 6 months after surgery. Improvement of symptom severity score of our series was 1.35 in the octogenarian group and 0.85 in the younger group, respectively. Our results regarding improvement of symptom severity were comparable with the results of Ozer et al22 considering the severe preoperative status in our patients. However, both groups did not achieve the improvement of function score beyond the minimal clinically important difference of 1.65 reported by Ozer et al.22 This study has several limitations. First, although improvement after carpal tunnel release is largely complete after 3 to 6 months,10,16,23 the follow-up period was not long enough to observe recovery of the thenar muscle wasting. Second, we classiﬁed the severity of CTS using electrophysiological assessment. Although electrophysiological studies are an objective assessment of nerve function in CTS patients, it is controversial whether symptoms are associated with Vol. 39, December 2014
ECTR FOR SEVERE CTS IN OCTOGENARIANS
electrophysiological ﬁndings.4,5,13,23 Third, although we objectively assessed thenar muscle function using APB-CMAP, subjective assessment of motor function and recovery of thenar muscle atrophy were not included in this study. Life expectancy of the Japanese population was 79.3 years for men and 85.9 years for women in 2010.24 Healthy life expectancies were 70.6 years and 75.6 years, respectively.24 Surgical treatment for CTS in octogenarians is not uncommon in our practice. Most of our patients in this series lived alone or independently and their hand function was of critical importance to them. The increase of aging populations worldwide requires better clinical decisionmaking data for CTS in the elderly. REFERENCES 1. Tomaino MM, Weiser RW. Carpal tunnel release for advanced disease in patients 70 years and older: does outcome from the patient’s perspective justify surgery? J Hand Surg Br. 2001;26(5):481e483. 2. Leit ME, Weiser RW, Tomaino MM. Patient-reported outcome after carpal tunnel release for advanced disease: a prospective and longitudinal assessment in patients older than age 70. J Hand Surg Am. 2004;29(3):379e383. 3. Weber RA, Rude MJ. Clinical outcomes of carpal tunnel release in 65 and older. J Hand Surg Am. 2005;30(1):75e80. 4. Townshend DN, Taylor PK, Gwynne-Jones DP. The outcome of carpal tunnel decompression in elderly patients. J Hand Surg Am. 2005;30(3):500e505. 5. Beck JD, Wingert NC, Rutter MR, Irgit KS, Tang X, Klena JC. Clinical outcomes of endoscopic carpal tunnel release in patients 65 and over. J Hand Surg Am. 2013;38(8):1524e1529. 6. Ettema AM, Amadio PC, Cha SS, Harrington JR, Harris AM, Offord KP. Surgery versus conservative therapy in carpal tunnel syndrome in people aged 70 years and older. Plast Reconstr Surg. 2006;118(4):947e958. 7. Nagaoka M, Nagano S, Matsuzaki H. Endoscopic carpal tunnel release in the elderly. Minim Invasive Neurosurg. 2006;49(4):216e219. 8. 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;30(6):599e604. 9. Hansen TB, Larsen K. Age is an important predictor of short-term outcome in endoscopic carpal tunnel release. J Hand Surg Eur Vol. 2009;34(5):660e664.
J Hand Surg Am.
10. Porter P, Venkateswaran B, Stephenson H, Wray CC. The inﬂuence of age on outcome after operation for the carpal tunnel syndrome. J Bone Joint Surg Br. 2002;84(5):688e691. 11. Wilgis EFS, Burke FD, Dubin NH, Sinha S, Bradley MJ. A prospective assessment of carpal tunnel surgery with respect to age. J Hand Surg Br. 2006;31(4):401e406. 12. Nobuta S, Sato K, Komatsu T, Miyasaka Y, Hatori M. Clinical results in severe carpal tunnel syndrome and motor nerve conduction studies. J Orthop Sci. 2005;10(1):22e26. 13. Choi SJ, Ahn DS. Correlation of clinical history and electrodiagnostic abnormalities with outcome after surgery for carpal tunnel syndrome. Plast Reconstr Surg. 1998;102(7):2374e2380. 14. Chow JCY. Endoscopic release of the carpal ligament: a new technique for carpal tunnel syndrome. Arthroscopy. 1989;5(1):19e24. 15. Imaeda T, Uchiyama S, Toh S, Wada T, et al. Validation of the Japanese Society for Surgery of the Hand version of the Carpal Tunnel Syndrome Instrument. J Orthop Sci. 2007;12(1):14e21. 16. Levine DW, Simmons BP, Koris MJ, et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993;75(11):1585e1592. 17. Atroshi I, Johnson R, Sprinchorn A. Self-administered outcome instrument in carpal tunnel syndrome: reliability, validity and responsiveness evaluated in 102 patients. Acta Orthop Scand. 1998;69(1): 82e88. 18. Itsubo T, Uchiyama S, Momose T, Yasutomi T, Imaeda T, Kato H. Electrophysiological responsiveness and quality of life (Quick DASH, CTSI) evaluation of surgically treated carpal tunnel syndrome. J Orthop Sci. 2009;14(1):17e23. 19. Vliet MMV, Maradey JA, Homa KA, Kerrigan CL. The usefulness of patient-reported measures for clinical practice. Plast Reconstr Surg. 2013;132(1):105e112. 20. Jaeschke R, Singer J, Guyatt GH. Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials. 1989;10(4):407e415. 21. Ӧzyürekoglu T, McCabe SJ, Goldsmith LJ, LaJoie AS. The minimal clinically important difference of the Carpal Tunnel Syndrome Symptom Severity Scale. J Hand Surg Am. 2006;31(5): 733e738. 22. Ozer K, Malay S, Toker S, Chung KC. Minimal clinically important difference of carpal tunnel release in diabetic and nondiabetic patients. Plast Reconstr Surg. 2013;131(6):1279e1285. 23. Mondelli M, Reale F, Sicurelli F, Padua I. Relationship between the self-administered Boston questionnaire and electrophysiological ﬁndings in follow-up of surgically-treated carpal tunnel syndrome. J Hand Surg Br. 2000;25(2):128e134. 24. Salomon JA, Wang H, Freeman MK, et al. Healthy life expectancy for 187 countries, 1990-2010: a systematic analysis for the Global Burden Disease Study 2010. Lancet. 2010;380(9859):2144e2162.
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