Perspectives Commentary on: Retractor-Endoscopic Nerve Decompression in Carpal and Cubital Tunnel Syndromes: Outcomes in a Small Series by Martin et al. World Neurosurg 2014 http://dx.doi.org/10.1016/j.wneu.2013.09.026
Rajiv Midha, M.D., M.Sc. Head, Department of Clinical Neurosciences Professor, Department of Clinical Neurosciences and Hotchkiss Brain Institute University of Calgary
Retractor-Assisted Endoscopic Nerve Decompression in Entrapment Neuropathy Chandan B. Mohanty and Rajiv Midha
arpal tunnel syndrome (CTS) and cubital tunnel syndrome (Cbts) are the most common entrapment neuropathy of the upper limb. Numerous studies have attempted to predict the best surgical modality for the management of CTS. The main surgical modalities are open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR). Multiple variations of the ECTR procedure exist of which single port and dual port ECTR are the most popular techniques.
C
life. It is interesting to note that ECTR is also avoided for complex cases where the patient has synovial cysts or space occupying lesions or patients with stiff arthritic joints (5). Thus the difficult and complex cases of CTS are treated with OCTR. Under-reporting of complications, especially with regard to a new technique, is another important confounding factor. It is clear from all of these factors that a true comparison among the published articles is extremely tricky and published surgical results should be thoroughly scrutinized.
The proposed advantages of ECTR are smaller incision, early postoperative recovery, decreased pain in the postoperative period, and improved grip strength (7, 9, 10). However ECTR has a longer learning curve and increased risk of reversible nerve injury (12). Other advantages have not shown any difference in the long-term outcome after OCTR and ECTR (1). Most of the OCTRs are now performed with an incision of 1.5e2 cm. A Cochrane review (10) showed no difference in outcome after either OCTR or ECTR. The review also stated that the use of either OCTR or ECTR is dictated by the preference of the patient or the surgeon. Another review (6) noted that the outcome measures were extremely variable and results were not reported in a sufficient detail to carry out appropriate statistical segregation. It similarly noted that measures like early return to work depends on factors like manual versus nonmanual labor, differences in health care systems, whether it is a unilateral or bilateral surgery, and nature of employment (self-employed or employee). The time to return to work also does not mean that the patient is pain free or satisfied with the procedure. The authors recommended that the minimum set of outcome measures for CTS that should be used are Boston Carpal Tunnel Questionnaire, clinical assessment of motor and sensory system, and every day performance in work, leisure, self-care, and health-related quality of
The outcome measures commonly used for Cbts are Michigan Hand Questionnaire, Carpal Tunnel Questionnaire (CTQ), Disabilities of the Arm, Shoulder, and Hand, and Patient-Rated Ulnar Nerve Evaluation. Out of these Michigan Hand Questionnaire, CTQ have shown to be better by the Surgery for the Ulnar nerve study group (11). A simple standardized outcome measure is essential to compare among the studies published in literature.
Key words Carpal tunnel syndrome - Cubital tunnel syndrome - Endoscopic decompression - Transpositions -
Abbreviations and Acronyms Cbts: Cubital tunnel syndrome CTQ: Carpal Tunnel Questionnaire CTS: Carpal tunnel syndrome ECTR: Endoscopic carpal tunnel release OCTR: Open carpal tunnel release
WORLD NEUROSURGERY - [-]: ---, MONTH 2014
In the article reported in this issue, Martin et al. describe their experience and results of use of retractor integrated endoscope for CTR, in situ ulnar nerve decompression, and anterior transposition after ulnar nerve decompression. They are to be congratulated for objectively and subjectively assessing the outcome after surgery at 2 years and demonstrate good outcome in all of the three types of surgery using the retractor-integrated endoscope. This article raises some questions. It is not clear whether the results reported are from a single surgeon or multiple surgeons. If it is a multiple surgeon series then did the surgeons have a varying experience/familiarity with the endoscope-based retractor? Martin et al. used a Bishop scale, which, however, does not take into consideration features such as nocturnal symptoms of pain,
Division of Neurosurgery and Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada To whom correspondence should be addressed: Rajiv Midha, M.D., M.Sc. [E-mail: [email protected]] Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.10.052
www.WORLDNEUROSURGERY.org
1
PERSPECTIVES
tingling, or factors like assessment of fine motor skills. Ideally, an outcome tool, like the Boston Carpal Tunnel Questionnaire, should have been used for assessment of CTS surgery, whereas one of the outcome measures described previously should have been used to evaluate outcomes for the ulnar nerve procedures. However, we do acknowledge that the results of comparison of these outcome studies were published only recently. It is now well established that simple decompression of the ulnar nerve and decompression with transposition are equally effective for the treatment of idiopathic Cbts, irrespective of the severity of Cbts (3). However, because in situ decompression is a simpler procedure with lesser morbidity and a low risk of iatrogenic nerve injury, simple in situ decompression is preferred over decompression and transposition in patients with Cbts. The indication for ulnar nerve transposition in the article is somewhat confusing. The usual indications of transposition are patients requiring redo decompression, patients with valgus or varus elbow deformities, or dislocation of the nerve across the medial epicondyle observed intraoperatively when the elbow is put through its complete range of motion. The need for ulnar nerve transposition is thus questionable in the series. It also raises a doubt whether the technique could be used in more complex cases requiring ulnar nerve transposition. This fact also emphasizes the point made earlier that endoscopic decompression and transposition should be avoided for complex cases. It appears from the illustration (Figure 9) that a redo decompression or cases with significant perineural scarring will be difficult to operate with the endoscope as the tissue planes will be more difficult to exploit. In such cases, use of the endoscope may in fact cause iatrogenic injury to the underlying nerve or to the overlying cutaneous nerve. The description of the surgical procedure of ulnar nerve transposition does not mention how other uncommon sites of possible compression are tackled—namely the arcade of Struthers, fascial bands distal to the flexor carpi ulnaris aponeurosis (flexor-pronator
REFERENCES 1. Atroshi I, Hofer M, Larsson GU, Ornstein E, Johnsson R, Ranstam J: Open compared with 2-portal endoscopic carpal tunnel release: a 5-year follow-up of a randomized controlled trial. J Hand Surg Am 34:266-272, 2009. 2. Bolster MA, Zophel OT, van den Heuvel ER, Ruettermann M: Cubital tunnel syndrome: a comparison of an endoscopic technique with a minimal invasive open technique. J Hand Surg Eur 2013 Jul 22 2013 Jul 22 [Epub ahead of print]. 3. Caliandro P, La Torre G, Padua R, Giannini F, Padua L: Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev 11(7):CD006839, 2012. 4. Chimenti PC, Hammert WC: Ulnar neuropathy at the elbow: an evidence-based algorithm. Hand Clin 29:435-442, 2013. 5. Erdmann MWH: Endoscopic carpal tunnel decompression. J Hand Surg 19:5-13, 1994.
2
www.SCIENCEDIRECT.com
aponeurosis) (8). It may be possible that these possible sites were not accessible by the endoscope as they are the most distal sites of compression. However, it may be possible to address this situation by making smaller incisions proximal and distal to the main incision. Further analysis of the article reveals that the only real difference between open ulnar nerve decompression and endoscopic ulnar nerve decompression is the size of incision, as all of the key steps and goals of surgery are the same. Literature comparing the outcomes of open versus endoscopic ulnar nerve decompression is scarce and the few articles comparing the two surgical techniques do not show any difference in outcome (2, 4). One of the possible applications of the endoscopic-retractor system, as pointed out by Martin et al., is its possible utility to harvest long nerve grafts with a smaller and lesser number of incisions. The most important message of this article is that the complication rate is similar in both open and endoscopic techniques as reported by Martin et al. Further well-designed prospective studies with standardized outcome measures will help in determining the real efficacy and value-added benefit of the technique. Another parameter, which determines popularity of a new technique, is the ability of the technique to produce similar clinical results consistently, by different surgeons. This will be the true test of the overall utility of the retractor-based endoscopic system. We congratulate Martin et al. in their surgical innovation in introducing a new technique in the management of these common entrapment neuropathies. However, as Leonardo Da Vinci eloquently quoted that “Simplicity is the ultimate sophistication,” we believe that in spite of the newer adjuncts in endoscopy to make endoscopy safer, at present, the simplicity and thorough decompression achieved by an open technique remains unmatched. Open decompression thus still remains the gold standard in the treatment of entrapment neuropathy.
6. Jerosch-Herold C, Leite JC, Song F: A systematic review of outcomes assessed in randomized controlled trials of surgical interventions for carpal tunnel syndrome using the International Classification of Functioning, Disability and Health (ICF) as a reference tool. BMC Musculoskelet Disord 5:96, 2006. 7. Kohanzadeh S, Herrera FA, Dobke M: Outcomes of open and endoscopic carpal tunnel release: a meta-analysis. Hand (N Y) 7:247-251, 2012.
11. Song JW, Waljee JF, Burns PB, Chung KC, Gaston RG, Haase SC, Hammert WC, Lawton JN, Merrell GA, Nassab PF, Yang LJ: An outcome study for ulnar neuropathy at the elbow: a multicenter study by the surgery for ulnar nerve (SUN) study group. Neurosurgery 72:971-981, 2013. 12. Thoma A, Veltri K, Haines T, Duku E: A metaanalysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression. Plast Reconstr Surg 114:1137-1146, 2004.
8. Posner MA: Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Orthop Surg 6:282-288, 1998. 9. Rabb CH, Kuether T: Initial experience with endoscopic carpal tunnel release surgery. Neurosurg Focus 3:e4, 1997.
Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.10.052
10. Scholten RJ, Mink van der Molen A, Uitdehaag BM, Bouter LM: de Vet HC: Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev 17(4) 2007:CD003905, 2007.
Available online: www.sciencedirect.com
Journal homepage: www.WORLDNEUROSURGERY.org
1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.10.052
Rajiv Midha, M.D., M.Sc. Head, Department of Clinical Neurosciences Professor, Department of Clinical Neurosciences and Hotchkiss Brain Institute University of Calgary
Retractor-Assisted Endoscopic Nerve Decompression in Entrapment Neuropathy Chandan B. Mohanty and Rajiv Midha
arpal tunnel syndrome (CTS) and cubital tunnel syndrome (Cbts) are the most common entrapment neuropathy of the upper limb. Numerous studies have attempted to predict the best surgical modality for the management of CTS. The main surgical modalities are open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR). Multiple variations of the ECTR procedure exist of which single port and dual port ECTR are the most popular techniques.
C
life. It is interesting to note that ECTR is also avoided for complex cases where the patient has synovial cysts or space occupying lesions or patients with stiff arthritic joints (5). Thus the difficult and complex cases of CTS are treated with OCTR. Under-reporting of complications, especially with regard to a new technique, is another important confounding factor. It is clear from all of these factors that a true comparison among the published articles is extremely tricky and published surgical results should be thoroughly scrutinized.
The proposed advantages of ECTR are smaller incision, early postoperative recovery, decreased pain in the postoperative period, and improved grip strength (7, 9, 10). However ECTR has a longer learning curve and increased risk of reversible nerve injury (12). Other advantages have not shown any difference in the long-term outcome after OCTR and ECTR (1). Most of the OCTRs are now performed with an incision of 1.5e2 cm. A Cochrane review (10) showed no difference in outcome after either OCTR or ECTR. The review also stated that the use of either OCTR or ECTR is dictated by the preference of the patient or the surgeon. Another review (6) noted that the outcome measures were extremely variable and results were not reported in a sufficient detail to carry out appropriate statistical segregation. It similarly noted that measures like early return to work depends on factors like manual versus nonmanual labor, differences in health care systems, whether it is a unilateral or bilateral surgery, and nature of employment (self-employed or employee). The time to return to work also does not mean that the patient is pain free or satisfied with the procedure. The authors recommended that the minimum set of outcome measures for CTS that should be used are Boston Carpal Tunnel Questionnaire, clinical assessment of motor and sensory system, and every day performance in work, leisure, self-care, and health-related quality of
The outcome measures commonly used for Cbts are Michigan Hand Questionnaire, Carpal Tunnel Questionnaire (CTQ), Disabilities of the Arm, Shoulder, and Hand, and Patient-Rated Ulnar Nerve Evaluation. Out of these Michigan Hand Questionnaire, CTQ have shown to be better by the Surgery for the Ulnar nerve study group (11). A simple standardized outcome measure is essential to compare among the studies published in literature.
Key words Carpal tunnel syndrome - Cubital tunnel syndrome - Endoscopic decompression - Transpositions -
Abbreviations and Acronyms Cbts: Cubital tunnel syndrome CTQ: Carpal Tunnel Questionnaire CTS: Carpal tunnel syndrome ECTR: Endoscopic carpal tunnel release OCTR: Open carpal tunnel release
WORLD NEUROSURGERY - [-]: ---, MONTH 2014
In the article reported in this issue, Martin et al. describe their experience and results of use of retractor integrated endoscope for CTR, in situ ulnar nerve decompression, and anterior transposition after ulnar nerve decompression. They are to be congratulated for objectively and subjectively assessing the outcome after surgery at 2 years and demonstrate good outcome in all of the three types of surgery using the retractor-integrated endoscope. This article raises some questions. It is not clear whether the results reported are from a single surgeon or multiple surgeons. If it is a multiple surgeon series then did the surgeons have a varying experience/familiarity with the endoscope-based retractor? Martin et al. used a Bishop scale, which, however, does not take into consideration features such as nocturnal symptoms of pain,
Division of Neurosurgery and Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada To whom correspondence should be addressed: Rajiv Midha, M.D., M.Sc. [E-mail: [email protected]] Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.10.052
www.WORLDNEUROSURGERY.org
1
PERSPECTIVES
tingling, or factors like assessment of fine motor skills. Ideally, an outcome tool, like the Boston Carpal Tunnel Questionnaire, should have been used for assessment of CTS surgery, whereas one of the outcome measures described previously should have been used to evaluate outcomes for the ulnar nerve procedures. However, we do acknowledge that the results of comparison of these outcome studies were published only recently. It is now well established that simple decompression of the ulnar nerve and decompression with transposition are equally effective for the treatment of idiopathic Cbts, irrespective of the severity of Cbts (3). However, because in situ decompression is a simpler procedure with lesser morbidity and a low risk of iatrogenic nerve injury, simple in situ decompression is preferred over decompression and transposition in patients with Cbts. The indication for ulnar nerve transposition in the article is somewhat confusing. The usual indications of transposition are patients requiring redo decompression, patients with valgus or varus elbow deformities, or dislocation of the nerve across the medial epicondyle observed intraoperatively when the elbow is put through its complete range of motion. The need for ulnar nerve transposition is thus questionable in the series. It also raises a doubt whether the technique could be used in more complex cases requiring ulnar nerve transposition. This fact also emphasizes the point made earlier that endoscopic decompression and transposition should be avoided for complex cases. It appears from the illustration (Figure 9) that a redo decompression or cases with significant perineural scarring will be difficult to operate with the endoscope as the tissue planes will be more difficult to exploit. In such cases, use of the endoscope may in fact cause iatrogenic injury to the underlying nerve or to the overlying cutaneous nerve. The description of the surgical procedure of ulnar nerve transposition does not mention how other uncommon sites of possible compression are tackled—namely the arcade of Struthers, fascial bands distal to the flexor carpi ulnaris aponeurosis (flexor-pronator
REFERENCES 1. Atroshi I, Hofer M, Larsson GU, Ornstein E, Johnsson R, Ranstam J: Open compared with 2-portal endoscopic carpal tunnel release: a 5-year follow-up of a randomized controlled trial. J Hand Surg Am 34:266-272, 2009. 2. Bolster MA, Zophel OT, van den Heuvel ER, Ruettermann M: Cubital tunnel syndrome: a comparison of an endoscopic technique with a minimal invasive open technique. J Hand Surg Eur 2013 Jul 22 2013 Jul 22 [Epub ahead of print]. 3. Caliandro P, La Torre G, Padua R, Giannini F, Padua L: Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev 11(7):CD006839, 2012. 4. Chimenti PC, Hammert WC: Ulnar neuropathy at the elbow: an evidence-based algorithm. Hand Clin 29:435-442, 2013. 5. Erdmann MWH: Endoscopic carpal tunnel decompression. J Hand Surg 19:5-13, 1994.
2
www.SCIENCEDIRECT.com
aponeurosis) (8). It may be possible that these possible sites were not accessible by the endoscope as they are the most distal sites of compression. However, it may be possible to address this situation by making smaller incisions proximal and distal to the main incision. Further analysis of the article reveals that the only real difference between open ulnar nerve decompression and endoscopic ulnar nerve decompression is the size of incision, as all of the key steps and goals of surgery are the same. Literature comparing the outcomes of open versus endoscopic ulnar nerve decompression is scarce and the few articles comparing the two surgical techniques do not show any difference in outcome (2, 4). One of the possible applications of the endoscopic-retractor system, as pointed out by Martin et al., is its possible utility to harvest long nerve grafts with a smaller and lesser number of incisions. The most important message of this article is that the complication rate is similar in both open and endoscopic techniques as reported by Martin et al. Further well-designed prospective studies with standardized outcome measures will help in determining the real efficacy and value-added benefit of the technique. Another parameter, which determines popularity of a new technique, is the ability of the technique to produce similar clinical results consistently, by different surgeons. This will be the true test of the overall utility of the retractor-based endoscopic system. We congratulate Martin et al. in their surgical innovation in introducing a new technique in the management of these common entrapment neuropathies. However, as Leonardo Da Vinci eloquently quoted that “Simplicity is the ultimate sophistication,” we believe that in spite of the newer adjuncts in endoscopy to make endoscopy safer, at present, the simplicity and thorough decompression achieved by an open technique remains unmatched. Open decompression thus still remains the gold standard in the treatment of entrapment neuropathy.
6. Jerosch-Herold C, Leite JC, Song F: A systematic review of outcomes assessed in randomized controlled trials of surgical interventions for carpal tunnel syndrome using the International Classification of Functioning, Disability and Health (ICF) as a reference tool. BMC Musculoskelet Disord 5:96, 2006. 7. Kohanzadeh S, Herrera FA, Dobke M: Outcomes of open and endoscopic carpal tunnel release: a meta-analysis. Hand (N Y) 7:247-251, 2012.
11. Song JW, Waljee JF, Burns PB, Chung KC, Gaston RG, Haase SC, Hammert WC, Lawton JN, Merrell GA, Nassab PF, Yang LJ: An outcome study for ulnar neuropathy at the elbow: a multicenter study by the surgery for ulnar nerve (SUN) study group. Neurosurgery 72:971-981, 2013. 12. Thoma A, Veltri K, Haines T, Duku E: A metaanalysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression. Plast Reconstr Surg 114:1137-1146, 2004.
8. Posner MA: Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Orthop Surg 6:282-288, 1998. 9. Rabb CH, Kuether T: Initial experience with endoscopic carpal tunnel release surgery. Neurosurg Focus 3:e4, 1997.
Citation: World Neurosurg. (2014). http://dx.doi.org/10.1016/j.wneu.2013.10.052
10. Scholten RJ, Mink van der Molen A, Uitdehaag BM, Bouter LM: de Vet HC: Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev 17(4) 2007:CD003905, 2007.
Available online: www.sciencedirect.com
Journal homepage: www.WORLDNEUROSURGERY.org
1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.10.052
