Carpal tunnel syndrome: modest benefit of surgery compared to non-surgical treatment

Carpal tunnel syndrome: modest benefit of surgery compared to non-surgical treatment

An article in this week's Surgery Special Issue of The Lancet reports that surgery for carpal tunnel syndrome in patients (without an indication of severe nerve damage known as denervation) provides better outcomes than non-surgical treatment. However, the clinical relevance of this difference is modest. The article is the work of Professor Jeffrey Jarvik, of the Harborview Medical Center, University of Washington, Seattle, USA, and colleagues.

The authors included 116 patients from eight centres in this randomised controlled trial. 57 patients were assigned to carpal tunnel surgery and 59 patients were assigned to a precise non-surgical treatment including hand therapy and ultrasound. The primary outcome was hand function. After 12 months, it was measured by the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ). This evaluation was implemented by research personnel uninformed of group assignment.

Results showed that 77 percent (44) of the patients assigned to surgery indeed underwent surgery. After 12 months, 87 percent (101 patients) completed follow-up and were analysed. 49 patients of the 57 assigned to surgery and 52 patients of 59 assigned to non-surgical treatment. The findings revealed a significant 12 month adjusted advantage for surgery in both function and symptoms. It was calculated by proportions of patients having at least a 30 percent improvement in CTSAQ scores for these indicators, and having minimal interference in daily work or housework activities. Among surgery patients, 46 percent met all three criteria. This compared to 27 percent for non-surgery patients.

The authors explain: "Overall, these data indicate that, in patients with carpal tunnel syndrome without denervation, surgery modestly improves hand function and symptoms by 3 months compared with a multimodality non-surgical treatment regimen, and this benefit is sustained through 1 year. However, some patients allocated to surgery reported persistent symptoms, and 61% of patients allocated to non-surgical treatment avoided surgery altogether. Our study, together with other previous evidence, indicates that surgery is useful for patients with carpal tunnel syndrome."

In an associated note, Dr Isam Atroshi, Hässleholm and Kristianstad Hospitals, and Lund University, Sweden, and Dr Christina Gummesson, Lund University, Sweden, remark: "Future studies should compare the overall costs of surgical and non-surgical treatments, to take into consideration all relevant aspects. Finally, patients' preference is important: faced with the need to wear a splint each night and during daytime for some weeks, some might prefer early surgery while others may prefer partial recovery to potential surgical risk. Nevertheless, patients with carpal tunnel syndrome who do not have satisfactory improvement with non-surgical treatment should be offered surgery."

"Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial"

Jeffrey G Jarvik, Bryan A Comstock, Michel Kliot, Judith A Turner, Leighton Chan, Patrick J Heagerty, William Hollingworth, Carolyn L Kerrigan,Richard A Deyo

Lancet 2009; 374: 1074-81

The Lancet

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Section Issues On Medicine: Medical practice