SCIENTIFIC ARTICLE
Trends in Carpal Tunnel Surgery: An Online Survey of Members of the American Society for Surgery of the Hand Justin J. Munns, MD, Hisham M. Awan, MD
Purpose To investigate the current treatment patterns of carpal tunnel surgery by members of the American Society of Surgeons of the Hand today and to assess how several elements of practice vary by surgeon location and experience. Methods An online survey consisting of 10 questions was sent electronically to members of the American Society of Surgeons of the Hand (N ¼ 2,413). A brief description of the study and a link were sent to participants by the investigators. Results were anonymously uploaded to an online spreadsheet. Results 716 hand surgeons (30%) responded to the survey. Surgeons were nearly equally represented by region. A wide variation in surgeon experience was observed. A majority (65%) performed most of their surgery at an outpatient surgical center. Preoperative electrodiagnostic testing was used, at least occasionally, by 90% of surgeons. Approximately one-half did not administer preoperative antibiotics at the time of surgery. Intravenous sedation with local anesthesia was the most common practice (43%), followed by Bier block (18%). A mini-open incision was most commonly used (50%). A minority reported using an orthosis postoperatively (29%), and they rarely prescribed a course of postoperative therapy (12%). Postoperative pain management was variable, with hydrocodone and derivatives given most commonly (61%). International practitioners were much less likely to operate in an outpatient surgical center (45%) or use antibiotics (13%). Younger surgeons were more likely to use electrodiagnostic testing (96%) compared with the mean (90%). Conclusions When compared with several previous similar studies, we noted a trend toward increased use of electrodiagnostic testing and decreased use of postoperative therapy and immobilization. (J Hand Surg Am. 2015;40(4):767e771. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Economic and decision analysis V. Key words Carpal tunnel syndrome, antibiotics, electrodiagnostics, postoperative therapy, pain management.
From The Hand and Upper Extremity Center, The Ohio State University Wexner Medical Center, Columbus, OH. Received for publication June 20, 2014; accepted in revised form December 4, 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: Hisham M. Awan, MD, The Hand and Upper Extremity Center, The Ohio State University, 915 Olentangy River Road, Suite 3200, Columbus, OH 43212; e-mail: [email protected]. 0363-5023/15/4004-0019$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.12.046
C
the most common compression neuropathy affecting the upper extremity, and more than 200,000 carpal tunnel releases are performed annually in the United States.1,2 Despite its prevalence, there is no clear consensus on several elements of surgical practice, including preoperative testing, surgical approach, and postoperative management.3e5 In 1987, Duncan et al published the results of a survey sent to members of the American Society of Surgeons of the Hand ARPAL TUNNEL SYNDROME REPRESENTS
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
767
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TRENDS IN CARPAL TUNNEL SURGERY
(ASSH) to identify their treatment practices.6 A few changes in the treatment of carpal tunnel surgery have occurred since then, such as endoscopic technique and mini-incision, and with those the common treatment practices also have changed. The purpose of our study was to investigate the current treatment patterns of carpal tunnel surgery by members of the ASSH today and to assess how several elements of practice vary by surgeon location and experience.
TABLE 1. South
24
Midwest
23
West
22
Northeast
20
International
11
Years in Practice
MATERIALS AND METHODS An on-line survey consisting of 10 questions was created and sent to members of ASSH. Permission was granted by the ASSH Web Site Committee to distribute the survey to members using the electronic mailing list. Active, candidate, and international practicing members of the ASSH (N ¼ 2413) were invited to complete the online survey. In total, 15% of ASSH members practice internationally. ASSH did not provide e-mail addresses for lifetime members. Because the survey focused on several elements of surgical management, hand therapists were excluded from participation. A brief description of the study and a link to obtain the study via a pop-up window were sent to participants. Results of the survey were anonymously uploaded to an online spreadsheet that allowed for tabulation of results (via Google Drive; Mountain View, CA), though participants were not granted access to results. Members were given 3 months to respond to the survey. This study was exempt from institutional review board approval at our institution. The 10-question survey aimed to assess critical elements in surgeons’ evaluation and treatment of carpal tunnel syndrome, and to capture key demographic information about the respondents. Demographic information included the surgeon’s region of practice (self-reported as either Northeast, South, Midwest, West, or abroad), years in practice, and most common surgical setting. Other questions assessed the use of electrodiagnostic testing, preferred surgical approach, type of anesthesia used, and antibiotic usage. Postoperative management was assessed with questions covering use of postoperative orthosis, therapy, and preferred pain treatment regimen. Estimated completion time of the survey was one minute. No additional follow-up inquiries were sent to participants. Analysis of results was performed in 2 stages. First, respondents’ answers to the full 10-question survey were tabulated as a whole using Microsoft Excel, with these results compared directly to percentages obtained from previous surveys (where applicable). Next, the J Hand Surg Am.
Demographics (%)
Region of Practice
Fewer than 3
10
3e10
23
11e20
32
21e30
26
More than 30
9
Surgical setting Outpatient facility
65
Community hospital
16
University
15
Office
2
Other
2
results were stratified by demographic subgroup, including the respondent’s region of practice, years of experience, and type of practice. This analysis was performed in order to assess differences in practice when each group was divided. RESULTS Seven hundred sixteen surgeons (30% of those solicited) responded to the survey. Incomplete question responses were excluded from analysis. Surgeons were nearly equally represented by U.S. region, and 11% were practicing abroad (Table 1). The largest representation of surgeons was in their 11th to 20th years of practice with the smallest representation in those with fewer than 3 years of experience and more than 30 years (Table 1). A majority of respondents performed most of their carpal tunnel surgery at an outpatient surgical center (Table 1; full data with questions included in Appendix A, available on the Journal’s Web site at www.jhandsurg.org). Preoperative electrodiagnostic testing (EMG and nerve conduction studies) were used, at least occasionally, by 90% of surgeons. Approximately one-half of respondents (49%) did not provide preoperative antibiotics at the time of surgery, with the remainder prescribing antibiotics at least a portion of the time. For sedation, intravenous sedation with local anesthesia was the most common practice, followed by use of a Bier block. For the incision, a mini-open incision was most commonly used (Table 2). r
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TRENDS IN CARPAL TUNNEL SURGERY
TABLE 2.
Intraoperative Survey Question Results (%) IV Sedation With Local
Bier Block
General
Wide Awake
Nerve Block
Wrist Block
Other
43
18
11
8
6
6
8
Mini-Open (Mid palmar)
Endoscopic, 1 Incision
Standard Open
Endoscopic, 2 Incision
Other
50
22
20
4
4
What type of anesthesia is used during your carpal tunnel release surgery?
What type of surgical approach do you use most often to perform a carpal tunnel release? IV, intravenous.
TABLE 3.
Postoperative Survey Question Results (%)
Do you usually recommend postoperative physical therapy?
YES
NO
88
12
Hydrocone þ Combination NSAIDS Oxycodone þ Non-Narcotics Other Derivatives Derivatives (excluding NSAIDS) What type of postoperative pain medications do you prescribe patients after a carpal tunnel release?
61
14
8
7
4
6
NSAIDS, nonsteroidal anti-inflammatory drugs.
Twenty-nine percent of respondents reported using an orthosis postoperatively (29%), and respondents rarely prescribed a course of therapy postoperatively. Postoperative pain management was variable, with hydrocodone and derivatives given most commonly, with a combination of agents used by some (Table 3). Responses were then stratified by area of practice (within the United States or abroad), years of experience, and the surgical practice location (eg, outpatient surgery center). When subclassified by area of practice, surgeons in the West more commonly used general anesthesia (17%) compared with all respondents (11%). Practitioners in the South were most likely to operate in an outpatient surgery center (74%). Practitioners in the Northeast were more likely to practice in a university setting (20%) and were less likely to use the wrist block for anesthesia compared with all respondents (3% and 6%, respectively). The responses from foreign practitioners had several distinct features: a higher incidence of operating in a university setting (33%) and a lower incidence of operating in an outpatient surgical center (45%); a lower incidence of antibiotic use (79% never use them); and for pain relief, 43% use non-steroidal anti-inflammatory drugs J Hand Surg Am.
alone, and 20% did not provide any narcotics at all. This may reflect the demographics of the international membership, which likely has a higher proportion of university-affiliated hand surgeons than ASSH membership in the United States. Surgeons with fewer than 3 years of operative experience were more likely to use antibiotics (67% at least occasionally, compared with 51% overall). This group was also more likely to use EMG/nerve conduction studies (96% vs. 89% overall) and more likely to use hydrocodone and derivatives for pain relief (75% vs. 61% overall). Few trends emerged for those in practice between 3 and 30 years. In contrast, surgeons with more than 30 years of experience, anesthetics administered were more common (19% use wrist block compared with 6% overall, and 22% use Bier block compared with 18% overall). For surgical approach, this group was less likely to perform an endoscopic approach (16% vs. 26% overall). DISCUSSION Three previous reports have investigated the common practices in carpal tunnel surgery. In 1987, Duncan et al r
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TRENDS IN CARPAL TUNNEL SURGERY
performed a survey of members of the ASSH.6 A 37-question survey was obtained from 722 members of the ASSH, with some overlap in queries compared to the present survey. Notable findings included routine use of electrodiagnostic studies by 38% of surgeons, and postoperative orthosis used by 82%. The most common approach performed was a standard longitudinal open approach greater than 4 cm in length (66%). That survey provided a benchmark for understanding how carpal tunnel surgery was performed nationwide. Because of the survey format, no statistically significant numbers could be reported, and findings as such represented how carpal tunnel surgery was performed by ASSH members. Leinberry et al performed a 25-year follow-up survey study modeled on the previous study and included some additional queries, and this was delivered to members of the ASSH members.7 Notable differences that emerged from the previous study were a decreased use of postoperative immobilization with orthosis (37%) and use of a mini-open incision most commonly. They also noted a 35% use of preoperative antibiotics, a question not previously asked. Additionally, Shin et al performed a 12-question online survey of 123 members of the American Association of Hand Surgery in 2012.8 Forty-six percent of respondents used a mini-open incision, and 20% used an endoscopic technique. Sixty-five percent of respondents used local anesthesia with or without intravenous sedation. Our survey questions possessed some overlap with the previous studies. The predominant use of a miniopen incision for carpal tunnel release was confirmed in our study, as 50% used this method and 26% used a 1-incision or 2-incision endoscopic technique. Similarly, recent literature questioning the efficacy of postoperative immobilization after release appears to have had an impact in treatment practices, as our study confirms the findings of Leinberry et al, with only 12% of our respondents using postoperative orthoses.9 Our study also confirmed the increased incidence of usage of electrodiagnostic studies among respondents, as 87% of respondents in the Leinberry et al study and 90% in our study obtain EMG or nerve conduction studies preoperatively, compared with 38% as noted by Duncan in 1987. Our study investigated several elements of carpal tunnel surgery not previously addressed. Surgeons in our study identified their primary operating theater as the outpatient surgery center, in 65% of cases. Perioperative antibiotics were used routinely or occasionally by 51% of surgeons surveyed, which represents a noteworthy proportion of surgeons despite recent J Hand Surg Am.
evidence suggesting perioperative antibiotics for soft tissue procedures, and carpal tunnel surgery in particular, is not indicated.10 Considerable differences, nonetheless, persists regarding antibiotic usage, and this is reflected in the survey findings. For pain management, 61% prescribed hydrocodone or derivatives to patients, 14% gave a combination of agents, and 8% gave oxycodone or derivatives. No long-term narcotics were administrated by any respondents. Some small differences in practice by location became apparent domestically (eg, surgeons in the Northeast were more likely to operate in a university setting), but more striking were the differences internationally, where both outpatient surgical centers and antibiotics were used much less frequently than domestically. Patterns of practice did not vary significantly from the composite results, aside from the surgeons with fewer than 3 or more than 30 years of experience. The increased use of EMG/nerve conduction studies (96%) by surgeons recently starting practice was notable, lending credence to the theory that objective evidence of disease is critical to medical decision making. Eight percent of our respondents used wide-awake anesthesia. Local anesthesia infiltration without sedation can be performed in an office setting with excellent results.11,12 The hand surgeons performing carpal tunnel surgery in an office setting (N ¼ 17) prefer this method of anesthesia (59%), followed by use of a wrist block (29%). No other notable trends became apparent when results were broken down by practice location. Also, general anesthesia was used in 11% of carpal tunnel surgeries performed by respondents. Further investigation of the reasons for choice of anesthesia was beyond the scope of our survey. Our study has several limitations. The survey format prevented any strong conclusions from being drawn from the data as a whole. The relatively low response incidence of 30% compared with some recent response rates of 50%13 leaves the results more prone to selection bias. It is unclear whether or not all of those people to whom the e-mails were addressed received the study because of spam filters and other blocking mechanisms. The 10-question format was designed to minimize strain on participants and encourage a greater degree of response, but this strategy also limited the amount of information that could be collected. Furthermore, a clearer delineation of what constituted a “mini-open incision” was not made in the on-line question, nor was a clear delineation of what constituted the surgeon’s geographic work area. Finally, the mailing list provided by ASSH did not include the 372 lifetime members, of r
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TRENDS IN CARPAL TUNNEL SURGERY
whom 230 were actively practicing and members of the ASSH for at least 30 years at the time of list access. This likely resulted in some selection bias.14
7. Leinberry CF, Rivlin M, Maltenfort M, et al. Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective. J Hand Surg Am. 2012;37(10): 1997e2003. e1993. 8. Shin EK, Bachoura A, Jacoby SM, Chen NC, Osterman AL. Treatment of carpal tunnel syndrome by members of the American Association for Hand Surgery. Hand (NY). 2012;7(4):351e356. 9. Huemer GM, Koller M, Pachinger T, Dunst KM, Schwarz B, Hintringer T. Postoperative splinting after open carpal tunnel release does not improve functional and neurological outcome. Muscle Nerve. 2007;36(4):528e531. 10. Tosti R, Fowler J, Dwyer J, Maltenfort M, Thoder JJ, Ilyas AM. Is antibiotic prophylaxis necessary in elective soft tissue hand surgery? Orthopedics. 2012;35(6):e829ee833. 11. Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014;30(1):1e6. 12. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (NY). 2013;8(1):47e53. 13. Payatakes AH, Zagoreos NP, Fedorcik GG, Ruch DS, Levin LS. Current practice of microsurgery by members of the American Society for Surgery of the Hand. J Hand Surg Am. 2007;32(4):541e547. 14. ASSH Lifetime Membership Category. Available at: http://admin. assh.org/Members/Benefits/Pages/Lifetime_Membership_Category.aspx. Accessed August 7, 2014.
REFERENCES 1. Harness NG, Inacio MC, Pfeil FF, Paxton LW. Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis. J Hand Surg Am. 2010;35(2):189e196. 2. Patterson JD, Simmons BP. Outcomes assessment in carpal tunnel syndrome. Hand Clin. 2002;18(2):359e363, viii. 3. Baker NA, Livengood HM. Symptom severity and conservative treatment for carpal tunnel syndrome in association with eventual carpal tunnel release. J Hand Surg Am. 2014;5(14):530e539. 4. Tarallo M, Fino P, Sorvillo V, Parisi P, Scuderi N. Comparative analysis between minimal access versus traditional accesses in carpal tunnel syndrome: a perspective randomised study. J Plast Reconstr Aesthet Surg. 2014;67(2):237e243. 5. Hansen TB, Majeed HG. Endoscopic carpal tunnel release. Hand Clin. 2014;30(1):47e53. 6. Duncan KH, Lewis RC Jr, Foreman KA, Nordyke MD. Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: Results of a questionnaire. J Hand Surg Am. May 1987;12(3):384e391.
J Hand Surg Am.
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APPENDIX A. Survey Questions and Responses QUESTION #1. you practice?
QUESTION #4. Do you routinely obtain a preoperative electromyelogram (EMG) or nerve conduction studies, or both, prior to performing a carpal tunnel release?
In what region of the country do Practice Location
Site
# Responses
Response Ratio (%)
Northeast
140
20
South
168
24
Midwest
163
23
159 82
West International Total
EMG/Nerve Conduction Studies Use
# Responses
Response Ratio (%)
Yes
513
72
22
No
76
11
11
Sometimes
125
18
Total
714
712
QUESTION #5. Do you use preoperative antibiotics before a carpal tunnel release?
QUESTION #2. How many years have you been in practice after completion of your training?
Preoperative Antibiotics
Years in Practice
Use
# Responses
Response Ratio (%)
259
36
Site
# Responses
Response Ratio (%)
Fewer than 3
71
10
No
350
49
3e10
164
23
Sometimes
106
15
11e20
227
32
Total
715
21e30
184
26
68
9
More than 30 Total
Yes
714
QUESTION #6. What type of anesthesia is used during your carpal tunnel release surgery?
QUESTION #3. In what setting are a majority of your carpal tunnel releases performed? Surgical Setting
# Responses
466
Response Ratio (%)
107
15
Community hospital
112
16
Office
17
2
Other
14
2
Total
716
Response Ratio (%)
IV sedation with local
309
43
Wrist block
45
6
Nerve block
44
6
Wide awake
65
University
# Responses
Form
Location Outpatient surgical center
Anesthetic
57
8
131
18
General
74
11
Other
57
8
Total
717
Bier block
IV, intravenous.
J Hand Surg Am.
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TRENDS IN CARPAL TUNNEL SURGERY
QUESTION #7. What type of surgical approach do you use most often to perform a carpal tunnel release?
QUESTION #10. What type of postoperative pain medications do you prescribe patients after a carpal tunnel release?
Incision
Postoperative Pain Regimen
Type
# Responses
Response Ratio (%)
Endoscopic, 1 incision
154
22
Endoscopic, 2 incision
32
4
Mini-open (midpalmar)
353
Standard open
142 29
Other Total
# Responses
Response Ratio (%)
NSAIDs
55
8
30
4
50
Non-narcotics (excluding NSAIDs)
20
Hydrocone þ derivatives
436
61
4
Oxycodone þ derivatives
51
7
0
0
Type
Oxycontin
710
Morphine sulfate (oral)
0
0
42
6
Combination
100
14
Total
714
Other
QUESTION #8. Do you apply a splint postoperatively?
IV, intravenous; NSAIDS, nonsteroidal anti-inflammatory drugs.
Splint Use Postoperatively Use
# Responses
Response Ratio (%)
Yes
193
27
No
501
71
16
2
Sometimes
QUESTION #9. Do you usually recommend postoperative physical therapy? Postoperative Therapy Use
# Responses
Response Ratio (%)
Yes
84
12
No
624
88
Total
708
J Hand Surg Am.
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Vol. 40, April 2015
Trends in Carpal Tunnel Surgery: An Online Survey of Members of the American Society for Surgery of the Hand Justin J. Munns, MD, Hisham M. Awan, MD
Purpose To investigate the current treatment patterns of carpal tunnel surgery by members of the American Society of Surgeons of the Hand today and to assess how several elements of practice vary by surgeon location and experience. Methods An online survey consisting of 10 questions was sent electronically to members of the American Society of Surgeons of the Hand (N ¼ 2,413). A brief description of the study and a link were sent to participants by the investigators. Results were anonymously uploaded to an online spreadsheet. Results 716 hand surgeons (30%) responded to the survey. Surgeons were nearly equally represented by region. A wide variation in surgeon experience was observed. A majority (65%) performed most of their surgery at an outpatient surgical center. Preoperative electrodiagnostic testing was used, at least occasionally, by 90% of surgeons. Approximately one-half did not administer preoperative antibiotics at the time of surgery. Intravenous sedation with local anesthesia was the most common practice (43%), followed by Bier block (18%). A mini-open incision was most commonly used (50%). A minority reported using an orthosis postoperatively (29%), and they rarely prescribed a course of postoperative therapy (12%). Postoperative pain management was variable, with hydrocodone and derivatives given most commonly (61%). International practitioners were much less likely to operate in an outpatient surgical center (45%) or use antibiotics (13%). Younger surgeons were more likely to use electrodiagnostic testing (96%) compared with the mean (90%). Conclusions When compared with several previous similar studies, we noted a trend toward increased use of electrodiagnostic testing and decreased use of postoperative therapy and immobilization. (J Hand Surg Am. 2015;40(4):767e771. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Economic and decision analysis V. Key words Carpal tunnel syndrome, antibiotics, electrodiagnostics, postoperative therapy, pain management.
From The Hand and Upper Extremity Center, The Ohio State University Wexner Medical Center, Columbus, OH. Received for publication June 20, 2014; accepted in revised form December 4, 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: Hisham M. Awan, MD, The Hand and Upper Extremity Center, The Ohio State University, 915 Olentangy River Road, Suite 3200, Columbus, OH 43212; e-mail: [email protected]. 0363-5023/15/4004-0019$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.12.046
C
the most common compression neuropathy affecting the upper extremity, and more than 200,000 carpal tunnel releases are performed annually in the United States.1,2 Despite its prevalence, there is no clear consensus on several elements of surgical practice, including preoperative testing, surgical approach, and postoperative management.3e5 In 1987, Duncan et al published the results of a survey sent to members of the American Society of Surgeons of the Hand ARPAL TUNNEL SYNDROME REPRESENTS
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
767
768
TRENDS IN CARPAL TUNNEL SURGERY
(ASSH) to identify their treatment practices.6 A few changes in the treatment of carpal tunnel surgery have occurred since then, such as endoscopic technique and mini-incision, and with those the common treatment practices also have changed. The purpose of our study was to investigate the current treatment patterns of carpal tunnel surgery by members of the ASSH today and to assess how several elements of practice vary by surgeon location and experience.
TABLE 1. South
24
Midwest
23
West
22
Northeast
20
International
11
Years in Practice
MATERIALS AND METHODS An on-line survey consisting of 10 questions was created and sent to members of ASSH. Permission was granted by the ASSH Web Site Committee to distribute the survey to members using the electronic mailing list. Active, candidate, and international practicing members of the ASSH (N ¼ 2413) were invited to complete the online survey. In total, 15% of ASSH members practice internationally. ASSH did not provide e-mail addresses for lifetime members. Because the survey focused on several elements of surgical management, hand therapists were excluded from participation. A brief description of the study and a link to obtain the study via a pop-up window were sent to participants. Results of the survey were anonymously uploaded to an online spreadsheet that allowed for tabulation of results (via Google Drive; Mountain View, CA), though participants were not granted access to results. Members were given 3 months to respond to the survey. This study was exempt from institutional review board approval at our institution. The 10-question survey aimed to assess critical elements in surgeons’ evaluation and treatment of carpal tunnel syndrome, and to capture key demographic information about the respondents. Demographic information included the surgeon’s region of practice (self-reported as either Northeast, South, Midwest, West, or abroad), years in practice, and most common surgical setting. Other questions assessed the use of electrodiagnostic testing, preferred surgical approach, type of anesthesia used, and antibiotic usage. Postoperative management was assessed with questions covering use of postoperative orthosis, therapy, and preferred pain treatment regimen. Estimated completion time of the survey was one minute. No additional follow-up inquiries were sent to participants. Analysis of results was performed in 2 stages. First, respondents’ answers to the full 10-question survey were tabulated as a whole using Microsoft Excel, with these results compared directly to percentages obtained from previous surveys (where applicable). Next, the J Hand Surg Am.
Demographics (%)
Region of Practice
Fewer than 3
10
3e10
23
11e20
32
21e30
26
More than 30
9
Surgical setting Outpatient facility
65
Community hospital
16
University
15
Office
2
Other
2
results were stratified by demographic subgroup, including the respondent’s region of practice, years of experience, and type of practice. This analysis was performed in order to assess differences in practice when each group was divided. RESULTS Seven hundred sixteen surgeons (30% of those solicited) responded to the survey. Incomplete question responses were excluded from analysis. Surgeons were nearly equally represented by U.S. region, and 11% were practicing abroad (Table 1). The largest representation of surgeons was in their 11th to 20th years of practice with the smallest representation in those with fewer than 3 years of experience and more than 30 years (Table 1). A majority of respondents performed most of their carpal tunnel surgery at an outpatient surgical center (Table 1; full data with questions included in Appendix A, available on the Journal’s Web site at www.jhandsurg.org). Preoperative electrodiagnostic testing (EMG and nerve conduction studies) were used, at least occasionally, by 90% of surgeons. Approximately one-half of respondents (49%) did not provide preoperative antibiotics at the time of surgery, with the remainder prescribing antibiotics at least a portion of the time. For sedation, intravenous sedation with local anesthesia was the most common practice, followed by use of a Bier block. For the incision, a mini-open incision was most commonly used (Table 2). r
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TRENDS IN CARPAL TUNNEL SURGERY
TABLE 2.
Intraoperative Survey Question Results (%) IV Sedation With Local
Bier Block
General
Wide Awake
Nerve Block
Wrist Block
Other
43
18
11
8
6
6
8
Mini-Open (Mid palmar)
Endoscopic, 1 Incision
Standard Open
Endoscopic, 2 Incision
Other
50
22
20
4
4
What type of anesthesia is used during your carpal tunnel release surgery?
What type of surgical approach do you use most often to perform a carpal tunnel release? IV, intravenous.
TABLE 3.
Postoperative Survey Question Results (%)
Do you usually recommend postoperative physical therapy?
YES
NO
88
12
Hydrocone þ Combination NSAIDS Oxycodone þ Non-Narcotics Other Derivatives Derivatives (excluding NSAIDS) What type of postoperative pain medications do you prescribe patients after a carpal tunnel release?
61
14
8
7
4
6
NSAIDS, nonsteroidal anti-inflammatory drugs.
Twenty-nine percent of respondents reported using an orthosis postoperatively (29%), and respondents rarely prescribed a course of therapy postoperatively. Postoperative pain management was variable, with hydrocodone and derivatives given most commonly, with a combination of agents used by some (Table 3). Responses were then stratified by area of practice (within the United States or abroad), years of experience, and the surgical practice location (eg, outpatient surgery center). When subclassified by area of practice, surgeons in the West more commonly used general anesthesia (17%) compared with all respondents (11%). Practitioners in the South were most likely to operate in an outpatient surgery center (74%). Practitioners in the Northeast were more likely to practice in a university setting (20%) and were less likely to use the wrist block for anesthesia compared with all respondents (3% and 6%, respectively). The responses from foreign practitioners had several distinct features: a higher incidence of operating in a university setting (33%) and a lower incidence of operating in an outpatient surgical center (45%); a lower incidence of antibiotic use (79% never use them); and for pain relief, 43% use non-steroidal anti-inflammatory drugs J Hand Surg Am.
alone, and 20% did not provide any narcotics at all. This may reflect the demographics of the international membership, which likely has a higher proportion of university-affiliated hand surgeons than ASSH membership in the United States. Surgeons with fewer than 3 years of operative experience were more likely to use antibiotics (67% at least occasionally, compared with 51% overall). This group was also more likely to use EMG/nerve conduction studies (96% vs. 89% overall) and more likely to use hydrocodone and derivatives for pain relief (75% vs. 61% overall). Few trends emerged for those in practice between 3 and 30 years. In contrast, surgeons with more than 30 years of experience, anesthetics administered were more common (19% use wrist block compared with 6% overall, and 22% use Bier block compared with 18% overall). For surgical approach, this group was less likely to perform an endoscopic approach (16% vs. 26% overall). DISCUSSION Three previous reports have investigated the common practices in carpal tunnel surgery. In 1987, Duncan et al r
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TRENDS IN CARPAL TUNNEL SURGERY
performed a survey of members of the ASSH.6 A 37-question survey was obtained from 722 members of the ASSH, with some overlap in queries compared to the present survey. Notable findings included routine use of electrodiagnostic studies by 38% of surgeons, and postoperative orthosis used by 82%. The most common approach performed was a standard longitudinal open approach greater than 4 cm in length (66%). That survey provided a benchmark for understanding how carpal tunnel surgery was performed nationwide. Because of the survey format, no statistically significant numbers could be reported, and findings as such represented how carpal tunnel surgery was performed by ASSH members. Leinberry et al performed a 25-year follow-up survey study modeled on the previous study and included some additional queries, and this was delivered to members of the ASSH members.7 Notable differences that emerged from the previous study were a decreased use of postoperative immobilization with orthosis (37%) and use of a mini-open incision most commonly. They also noted a 35% use of preoperative antibiotics, a question not previously asked. Additionally, Shin et al performed a 12-question online survey of 123 members of the American Association of Hand Surgery in 2012.8 Forty-six percent of respondents used a mini-open incision, and 20% used an endoscopic technique. Sixty-five percent of respondents used local anesthesia with or without intravenous sedation. Our survey questions possessed some overlap with the previous studies. The predominant use of a miniopen incision for carpal tunnel release was confirmed in our study, as 50% used this method and 26% used a 1-incision or 2-incision endoscopic technique. Similarly, recent literature questioning the efficacy of postoperative immobilization after release appears to have had an impact in treatment practices, as our study confirms the findings of Leinberry et al, with only 12% of our respondents using postoperative orthoses.9 Our study also confirmed the increased incidence of usage of electrodiagnostic studies among respondents, as 87% of respondents in the Leinberry et al study and 90% in our study obtain EMG or nerve conduction studies preoperatively, compared with 38% as noted by Duncan in 1987. Our study investigated several elements of carpal tunnel surgery not previously addressed. Surgeons in our study identified their primary operating theater as the outpatient surgery center, in 65% of cases. Perioperative antibiotics were used routinely or occasionally by 51% of surgeons surveyed, which represents a noteworthy proportion of surgeons despite recent J Hand Surg Am.
evidence suggesting perioperative antibiotics for soft tissue procedures, and carpal tunnel surgery in particular, is not indicated.10 Considerable differences, nonetheless, persists regarding antibiotic usage, and this is reflected in the survey findings. For pain management, 61% prescribed hydrocodone or derivatives to patients, 14% gave a combination of agents, and 8% gave oxycodone or derivatives. No long-term narcotics were administrated by any respondents. Some small differences in practice by location became apparent domestically (eg, surgeons in the Northeast were more likely to operate in a university setting), but more striking were the differences internationally, where both outpatient surgical centers and antibiotics were used much less frequently than domestically. Patterns of practice did not vary significantly from the composite results, aside from the surgeons with fewer than 3 or more than 30 years of experience. The increased use of EMG/nerve conduction studies (96%) by surgeons recently starting practice was notable, lending credence to the theory that objective evidence of disease is critical to medical decision making. Eight percent of our respondents used wide-awake anesthesia. Local anesthesia infiltration without sedation can be performed in an office setting with excellent results.11,12 The hand surgeons performing carpal tunnel surgery in an office setting (N ¼ 17) prefer this method of anesthesia (59%), followed by use of a wrist block (29%). No other notable trends became apparent when results were broken down by practice location. Also, general anesthesia was used in 11% of carpal tunnel surgeries performed by respondents. Further investigation of the reasons for choice of anesthesia was beyond the scope of our survey. Our study has several limitations. The survey format prevented any strong conclusions from being drawn from the data as a whole. The relatively low response incidence of 30% compared with some recent response rates of 50%13 leaves the results more prone to selection bias. It is unclear whether or not all of those people to whom the e-mails were addressed received the study because of spam filters and other blocking mechanisms. The 10-question format was designed to minimize strain on participants and encourage a greater degree of response, but this strategy also limited the amount of information that could be collected. Furthermore, a clearer delineation of what constituted a “mini-open incision” was not made in the on-line question, nor was a clear delineation of what constituted the surgeon’s geographic work area. Finally, the mailing list provided by ASSH did not include the 372 lifetime members, of r
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TRENDS IN CARPAL TUNNEL SURGERY
whom 230 were actively practicing and members of the ASSH for at least 30 years at the time of list access. This likely resulted in some selection bias.14
7. Leinberry CF, Rivlin M, Maltenfort M, et al. Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective. J Hand Surg Am. 2012;37(10): 1997e2003. e1993. 8. Shin EK, Bachoura A, Jacoby SM, Chen NC, Osterman AL. Treatment of carpal tunnel syndrome by members of the American Association for Hand Surgery. Hand (NY). 2012;7(4):351e356. 9. Huemer GM, Koller M, Pachinger T, Dunst KM, Schwarz B, Hintringer T. Postoperative splinting after open carpal tunnel release does not improve functional and neurological outcome. Muscle Nerve. 2007;36(4):528e531. 10. Tosti R, Fowler J, Dwyer J, Maltenfort M, Thoder JJ, Ilyas AM. Is antibiotic prophylaxis necessary in elective soft tissue hand surgery? Orthopedics. 2012;35(6):e829ee833. 11. Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014;30(1):1e6. 12. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (NY). 2013;8(1):47e53. 13. Payatakes AH, Zagoreos NP, Fedorcik GG, Ruch DS, Levin LS. Current practice of microsurgery by members of the American Society for Surgery of the Hand. J Hand Surg Am. 2007;32(4):541e547. 14. ASSH Lifetime Membership Category. Available at: http://admin. assh.org/Members/Benefits/Pages/Lifetime_Membership_Category.aspx. Accessed August 7, 2014.
REFERENCES 1. Harness NG, Inacio MC, Pfeil FF, Paxton LW. Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis. J Hand Surg Am. 2010;35(2):189e196. 2. Patterson JD, Simmons BP. Outcomes assessment in carpal tunnel syndrome. Hand Clin. 2002;18(2):359e363, viii. 3. Baker NA, Livengood HM. Symptom severity and conservative treatment for carpal tunnel syndrome in association with eventual carpal tunnel release. J Hand Surg Am. 2014;5(14):530e539. 4. Tarallo M, Fino P, Sorvillo V, Parisi P, Scuderi N. Comparative analysis between minimal access versus traditional accesses in carpal tunnel syndrome: a perspective randomised study. J Plast Reconstr Aesthet Surg. 2014;67(2):237e243. 5. Hansen TB, Majeed HG. Endoscopic carpal tunnel release. Hand Clin. 2014;30(1):47e53. 6. Duncan KH, Lewis RC Jr, Foreman KA, Nordyke MD. Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: Results of a questionnaire. J Hand Surg Am. May 1987;12(3):384e391.
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APPENDIX A. Survey Questions and Responses QUESTION #1. you practice?
QUESTION #4. Do you routinely obtain a preoperative electromyelogram (EMG) or nerve conduction studies, or both, prior to performing a carpal tunnel release?
In what region of the country do Practice Location
Site
# Responses
Response Ratio (%)
Northeast
140
20
South
168
24
Midwest
163
23
159 82
West International Total
EMG/Nerve Conduction Studies Use
# Responses
Response Ratio (%)
Yes
513
72
22
No
76
11
11
Sometimes
125
18
Total
714
712
QUESTION #5. Do you use preoperative antibiotics before a carpal tunnel release?
QUESTION #2. How many years have you been in practice after completion of your training?
Preoperative Antibiotics
Years in Practice
Use
# Responses
Response Ratio (%)
259
36
Site
# Responses
Response Ratio (%)
Fewer than 3
71
10
No
350
49
3e10
164
23
Sometimes
106
15
11e20
227
32
Total
715
21e30
184
26
68
9
More than 30 Total
Yes
714
QUESTION #6. What type of anesthesia is used during your carpal tunnel release surgery?
QUESTION #3. In what setting are a majority of your carpal tunnel releases performed? Surgical Setting
# Responses
466
Response Ratio (%)
107
15
Community hospital
112
16
Office
17
2
Other
14
2
Total
716
Response Ratio (%)
IV sedation with local
309
43
Wrist block
45
6
Nerve block
44
6
Wide awake
65
University
# Responses
Form
Location Outpatient surgical center
Anesthetic
57
8
131
18
General
74
11
Other
57
8
Total
717
Bier block
IV, intravenous.
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QUESTION #7. What type of surgical approach do you use most often to perform a carpal tunnel release?
QUESTION #10. What type of postoperative pain medications do you prescribe patients after a carpal tunnel release?
Incision
Postoperative Pain Regimen
Type
# Responses
Response Ratio (%)
Endoscopic, 1 incision
154
22
Endoscopic, 2 incision
32
4
Mini-open (midpalmar)
353
Standard open
142 29
Other Total
# Responses
Response Ratio (%)
NSAIDs
55
8
30
4
50
Non-narcotics (excluding NSAIDs)
20
Hydrocone þ derivatives
436
61
4
Oxycodone þ derivatives
51
7
0
0
Type
Oxycontin
710
Morphine sulfate (oral)
0
0
42
6
Combination
100
14
Total
714
Other
QUESTION #8. Do you apply a splint postoperatively?
IV, intravenous; NSAIDS, nonsteroidal anti-inflammatory drugs.
Splint Use Postoperatively Use
# Responses
Response Ratio (%)
Yes
193
27
No
501
71
16
2
Sometimes
QUESTION #9. Do you usually recommend postoperative physical therapy? Postoperative Therapy Use
# Responses
Response Ratio (%)
Yes
84
12
No
624
88
Total
708
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