Trends in Open vs. Endoscopic Carpal Tunnel Release: A Comprehensive Survey in Japan.
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ABSTRACT:
SUBMITTER: Yamamoto M
PROVIDER: S-EPMC9456605 | biostudies-literature | 2022 Aug
REPOSITORIES: biostudies-literature
Publications
Trends in Open vs. Endoscopic Carpal Tunnel Release: A Comprehensive Survey in Japan.
Yamamoto Michiro M Curley James J Hirata Hitoshi H
Journal of clinical medicine 20220824 17
We analyzed trends in open and endoscopic carpal tunnel release (CTR) from 2014 to 2019 using the National Database of Health Insurance Claims and Specific Health Checkups in Japan (NDB). Japan has a universal health insurance system and more than 95% of all claims are searchable in the NDB open data repository. The results revealed that nearly 40,000 CTRs were performed annually in Japan, and open CTR was performed almost 4 times more often than endoscopic CTR. The crude annual incidence of CTR ...[more]
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Project description:BackgroundCarpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR.MethodsWe developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs).ResultsECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations.ConclusionsFrom a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia.Level of evidenceEconomic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.
| S-EPMC8177000 | biostudies-literature
Project description:Background: Endoscopic carpal tunnel release (ECTR) has purported advantages over open release such as reduced intraoperative dissection and trauma and more rapid recovery. Endoscopic carpal tunnel release has been shown to have comparable outcomes to open release, but open release is considered easier and safer to perform. Previous studies have demonstrated an increase in carpal tunnel volume, regardless of the technique used. However, the mechanism by which this volumetric increase occurs has been debated. Our study will determine through magnetic resonance imaging (MRI) analysis the morphologic changes that occur in both open carpal tunnel release (OCTR) and ECTR, thereby clarifying any morphologic differences that occur as a result of the 2 operative techniques. We hypothesize that there will be no morphologic differences between the 2 techniques. Methods: This was a prospective study to compare the postoperative anatomy of both techniques with MRI. Nineteen patients with clinical and nerve conduction study-confirmed carpal tunnel syndrome underwent either open or endoscopic release. Magnetic resonance imaging was performed preoperatively and 6 months postoperatively in all patients to examine the volume of the carpal tunnel, transverse distance, anteroposterior (AP) distance, divergence of tendons, and Guyon's canal transverse and AP distance. Results: There was no significant difference in the postoperative morphology of the carpal tunnel and median nerve between OCTR and ECTR at 6-month follow-up on MRI. Conclusion: We conclude that there are no morphologic differences in OCTR and ECTR. It is an increase in the AP dimension that appears to be responsible for the increase in the volume of the carpal tunnel.
| S-EPMC8120591 | biostudies-literature
Project description:ImportanceCarpal tunnel release (CTR) technique may influence the likelihood of revision surgery. Prior studies of revision CTR following endoscopic CTR (ECTR) compared with open CTR (OCTR) have been limited by sample size and duration of follow-up.ObjectiveTo estimate the incidence of revision CTR following ECTR compared with OCTR in a national cohort.Design, setting, and participantsThis retrospective cohort study used data from the US Veterans Health Administration. Participants included all adults (age ≥18 years) undergoing at least 1 outpatient CTR from October 1, 1999, to May 20, 2021. Data were analyzed from May 21, 2021, to November 27, 2023.ExposureIndex CTR technique.Main outcomes and measuresThe primary outcome was time to revision CTR, defined as repeat ipsilateral CTR during the study period. Secondary outcomes were indications for revision, findings during revision, and additional procedures performed during revision.ResultsAmong 134 851 wrists from 103 455 patients (92 510 [89.4%] male; median [IQR] age, 62 [53-70] years) undergoing at least 1 CTR, 1809 wrists underwent at least 1 revision at a median (IQR) of 2.5 (1.0-3.8) years. In competing-risks analysis, the cumulative incidence of revision was 1.06% (95% CI, 0.99%-1.12%) at 5 years and 1.59% (95% CI, 1.51%-1.67%) at 10 years. ECTR was associated with increased hazard of revision CTR compared with OCTR (adjusted hazard ratio [aHR], 1.56; 95% CI, 1.34-1.81; P < .001). The risk difference for revision CTR associated with ECTR compared with OCTR was 0.57% (95% CI, 0.31%-0.84%) at 5 years (number needed to harm, 176) and 0.72% (95% CI, 0.36%-1.07%) at 10 years (number needed to harm, 139). Regardless of index CTR technique, the most common indication for revision was symptom recurrence (1062 wrists [58.7%]). A reconstituted transverse carpal ligament (TCL) was more common after ECTR compared with OCTR, whereas scarring of the overlying tissues and of the median nerve itself were more common following OCTR. Incomplete transverse-carpal-ligament release was observed in 251 of the wrists undergoing revision CTR (13.94%) and was more common among revisions following ECTR (odds ratio, 1.62; 95% CI, 1.11-2.37; P = .01).Conclusions and relevanceIn this cohort study of revision CTR in the Veterans Health Administration, ECTR was associated with increased risk of revision compared with OCTR, but the absolute risk was low regardless of technique. Intraoperative findings at revision varied significantly according to index CTR technique.
| S-EPMC10787312 | biostudies-literature
Project description:ObjectiveTo investigate changes in the median nerve, retinaculum, and carpal tunnel on ultrasound after successful endoscopic carpal tunnel release (ECTR).Materials and methodsThis prospective study involved 37 wrists in 35 patients (5 male, 30 female; mean age ± standard deviation [SD], 56.9 ± 6.7 years) with primary carpal tunnel syndrome (CTS). An in-house developed scoring system (0-3) was used to gauge the clinical improvement after ECTR. Ultrasound was performed before ECTR, and at 1, 3, and 12 months post-ECTR. Changes in the median nerve, flexor retinaculum, and carpal tunnel morphology on ultrasound after ECTR were analyzed. Ultrasound parameters for different clinical improvement groups were compared.ResultsAll patients improved clinically after ECTR. The average clinical improvement score ± SD at 12 months post-ECTR was 2.2 ± 0.7. The median nerve cross-sectional area proximal and distal to the tunnel decreased at all time intervals post-ECTR but remained swollen compared to normal values. Serial changes in the median nerve caliber and retinacular bowing after ECTR were more pronounced at the tunnel outlet than at the tunnel inlet. The flexor retinaculum had reformed in 25 (68%) of 37 wrists after 12 months.ConclusionPostoperative changes in median nerve and retinaculum parameters were most pronounced at the tunnel outlet. Even in patients with clinical improvement after ECTR, nearly all ultrasound parameters remain abnormal at one year post-ECTR. These ultrasound parameters should not necessarily be relied upon to diagnose persistent CTS after ECTR.
| S-EPMC8236373 | biostudies-literature
Project description:Various surgical procedures for carpal tunnel syndrome exist, such as open release, ultrasound-guided percutaneous release, and endoscopic release. Postoperative pain, scarring, and slow recovery to normal function are reported complications of open release. Damage to vessels and the median nerve and its branches underlying the transverse carpal ligament is a reported complication of ultrasound-guided percutaneous release. Damage to the superficial palmar arch and incomplete release are reported complications of endoscopic release. By performing endoscopic carpal tunnel release with ultrasound assistance, we could visualize neurovascular structures directly with the endoscope and also indirectly with ultrasound to minimize complications. We could also evaluate the morphologic changes of the median nerve dynamically before and after the release. We discuss the technique for this procedure and outline pearls and pitfalls for success.
| S-EPMC5021238 | biostudies-literature
Project description:Background: Surgical management of carpal tunnel syndrome includes performing an endoscopic (ECTR) or open (OCTR) carpal tunnel release. Several studies have shown less postoperative pain and improvement in grip and pinch strength with the endoscopic technique. The goal of this study was to prospectively examine outcomes, patient satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient. Methods: This was a prospective study in which patients with bilateral carpal tunnel syndrome underwent surgical release with both techniques, with initial operative approach randomized in the more symptomatic hand. Demographic data and functional outcomes were recorded, including the pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength testing, grip strength, carpal tunnel syndrome functional status score, carpal tunnel syndrome symptom severity score, and overall satisfaction. Results: Thirty patients completed the study; there were no significant differences in any measure at any of the postoperative time points. Symptom severity and functional status scores were not significantly different between groups at any evaluation. Subjectively, 24 of 30 patients did state they preferred the ECTR, mostly citing less pain as their primary reason, although pain scores were not significantly different. Differences in overall satisfaction were also not significant. Conclusions: Both techniques are well tolerated with no differences in outcomes. With the added cost and equipment associated with ECTR, and no added benefit, the usefulness of ECTR is questionable.
| S-EPMC7225896 | biostudies-literature
Project description:ObjectiveThe authors performed an intra-individual comparison of surgical results between the open and endoscopic surgical techniques in patients with bilateral carpal tunnel syndrome. Each hand was submitted to surgery using one of these techniques.MethodsFifteen patients (30 hands) were evaluated by the Boston Questionnaire, visual analogue pain scale, palmar grip strength, and for tip, key, and tripod pinch strengths. These measurements were taken before surgery and at two weeks, one month, three months, and six months after the procedure. Scores for each evaluation tool in each evaluation time period were compared.ResultsIn comparison to the group submitted to open surgery, the group submitted to endoscopic surgery had worse scores in the evaluation of the 1st and 6th postoperative months regarding the severity of the symptoms. The authors found no differences in the functional status of the hand. Regarding the intensity of pain evaluated by the visual analogue pain scale, no difference was found between the averages in all time periods evaluated. No differences in palmar grip strength and in fingertip, key (lateral), and tripod pinch strengths were found in all time periods. There were no differences between averages in the preoperative period at two weeks, one month, and three months after surgery. After six months, the group of patients submitted to open surgery presented greater tripod force than the group of patients who underwent endoscopic surgery.ConclusionNo differences were observed by using the intra-individual evaluation in the results between open and endoscopic techniques for the treatment of carpal tunnel syndrome.
| S-EPMC6204539 | biostudies-literature
Project description:Established endoscopic carpal tunnel release (ECTR) techniques carry a not entirely eludible risk of iatrogenic complications, mainly because of incomplete view of the cutting blade and intraoperative pressure increase inside the carpal tunnel (CT). We describe a novel single-portal ECTR method, conceived to reduce these risks, by optimizing visual control and avoiding dilatation of the CT. After incising the well exposed proximal third of the transverse carpal ligament (TCL), transection of the remainder is completed using a pediatric urethrotome. This small caliber instrument is moved in the plane of the TCL, without invading the tunnel, and provides detailed view of the TCL and any crossing anatomical structures at any given moment. We present the technique and the results of a retrospective case series of 33 patients with CT syndrome who underwent the procedure, after failing to respond to conservative treatment. Because of improved view and the avoidance of intraoperative pressure trauma to structures passing through the CT, the described approach may contribute to prevent iatrogenic complications and represent a valid improvement over conventional ECTR procedures.
| S-EPMC8876420 | biostudies-literature
Project description:BACKGROUND:Endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) both have advantages and disadvantages for the treatment of carpal tunnel syndrome (CTS). We compared the effectiveness and safety of ECTR and OCTR based on evidence from a high-level randomized controlled trial. METHODS:We comprehensively searched PubMed, EMBASE, Cochrane Library, Web of Science, and Medline to identify relevant articles published until August 2019. Data regarding operative time, grip strength, Boston Carpal Tunnel Questionnaire scores, digital sensation, patient satisfaction, key pinch strength, return to work time, and complications were extracted and compared. All mean differences (MD) and odds ratios (OR) were expressed as ECTR relative to OCTR. RESULTS:Our meta-analysis contained twenty-eight studies. ECTR was associated with significantly higher satisfaction rates (MD, 3.13; 95% confidence interval [CI], 1.43 to 4.82; P?=?0.0003), greater key pinch strengths (MD, 0.79?kg; 95% CI, 0.27 to 1.32; P?=?0.003), earlier return to work times (MD, -?7.25?days; 95% CI, -?14.31 to -?0.19; P?=?0.04), higher transient nerve injury rates (OR, 4.87; 95% CI, 1.37 to 17.25; P?=?0.01), and a lower incidence of scar-related complications (OR, 0.20; 95% CI, 0.07 to 0.59; P?=?0.004). The permanent nerve injury showed no significant differences between the two methods (OR, 1.93; 95% CI, 0.58 to 6.40; P?=?0.28). CONCLUSIONS:Overall, evidence from randomized controlled trials indicates that ECTR results in better recovery of daily life functions compared to OCTR, as revealed by higher satisfaction rates, greater key pinch strengths, earlier return to work times, and fewer scar-related complications. Our findings suggest that patients with CTS can be effectively managed with ECTR.
| S-EPMC7187537 | biostudies-literature
Project description:BACKGROUND:Carpal tunnel syndrome is a common compressive neuropathy of the median nerve. The efficacy and safety of endoscopic versus open carpal tunnel release remain controversial. QUESTIONS/PURPOSES:The purpose of this study was to determine whether endoscopic compared with open carpal tunnel release provides better symptom relief, validated outcome scores, short- and long-term strength, and/or digital sensibility; entails a differential risk of complications such as nerve injury, scar tenderness, pillar pain, and reoperation; allows an earlier return to work; and takes less operative time. METHODS:The English-language literature was searched using MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials that compared endoscopic and open carpal tunnel release were included in the meta-analysis. Methodologic quality was assessed with the Consolidated Standards Of Reporting Trials (CONSORT) checklist, and a sensitivity analysis was performed. Symptom relief, Boston Carpal Tunnel Questionnaire (BCTQ) scores, strength, digital sensibility, complications, reoperation, interval to return to work, and operative time were analyzed. Twenty-one randomized controlled trials containing 1859 hands were included. RESULTS:Endoscopically treated patients showed similar symptom relief and BCTQ scores; better early recovery of grip strength (mean difference [MD], 3.03 kg [0.08-5.98]; p = 0.04) and pinch strength (MD, 0.77 kg [0.33-1.22]; p < 0.001) but no advantage after 6 months; lower risk of scar tenderness (risk ratio [RR], 0.53 [0.35-0.82]; p = 0.005); higher risk of nerve injury (RR, 2.84 [1.08-7.46]; p = 0.03), most of which were transient neurapraxias. Similar risk of pillar pain and reoperation; an earlier return to work (MD, -8.73 days [-12.82 to -4.65]; p < 0.001); and reduced operative time (MD, -4.81 minutes [-9.23 to -0.39]; p = 0.03). CONCLUSIONS:High-level evidence from randomized controlled trials indicates that endoscopic release allows earlier return to work and improved strength during the early postoperative period. Results at 6 months or later are similar according to current data except that patients undergoing endoscopic release are at greater risk of nerve injury and lower risk of scar tenderness compared with open release. While endoscopic release may appeal to patients who require an early return to work and activities, surgeons should be cognizant of its elevated incidence of transient nerve injury amid its similar overall efficacy to open carpal tunnel release. Additional research is required to define the learning curve of endoscopic release and clarify the influence of surgeon volume on its safety.
| S-EPMC4317413 | biostudies-other