Clinical and neurophysiological outcome of surgery in extreme carpal tunnel syndrome

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Abstract

Introduction: Surgical release is the most effective therapy for the symptoms of carpal tunnel syndrome (CTS). It is widely considered that surgery may be ineffective in ‘extreme’ cases (those with atrophy of the thenar eminence muscles and no sensory and motor response of the median nerve).

Objective: To report clinical and eletrophysiological outcome of 10 subjects with ‘extreme’ CTS surgically treated.

Methods: Ten hands belonging to 10 patients (9 women and one man, mean age 65 years) underwent surgical release by the mini-incision of the palm technique. All showed atrophy of thenar eminence and absence of motor and sensory responses of the median nerve. The protocol consisted of clinical and electrophysiological evaluation, with the patient completing the self-administered Boston questionnaire (BQ) before the operation and one and 6 months after it.

Results: After surgical release, all patients reported an absence of pain and disappearance or reduction of paraesthesia. Six months after the operation, motor and sensory responses of the median nerve returned in 8 and 5 hands, respectively. The BQ showed a significant improvement in symptom and functional scores, although muscle atrophy remained unchanged. No correlation was found between the degree of clinical and electrical improvement and the age of the patients.

Conclusion: It is possible to obtain good clinical and electrophysiological results even in extreme cases of CTS.

Introduction

Decompression of the median nerve at the wrist is a common surgical procedure for carpal tunnel syndrome (CTS) and usually provides relief (Hybbinette and Mannerfelt, 1975), but it is not clear whether immediate surgery is better than conservative treatment (Johnson, 1995, Wilson and Summer, 1995, Eisen, 1995, Rosenbaum, 1999).In previous studies we evaluated post-operative prognosis on the basis of pre-operative neurophysiological assessment. We concluded that surgery is indicated even in ‘severe CTS’ (absence of median sensory responses and increment of median distal motor latency), because although postoperative electrodiagnostic values do not normalize, complete resolution of symptoms is possible (Padua et al., 1996).No studies have focused on surgical outcome in ‘extreme’ cases of CTS, namely those in which no median sensory and motor response is detectable (Padua et al., 1997).

Here we report the results of pre- and post-operative (1 and 6 months) neurophysiological and patient-oriented follow-up in 10 extreme cases of CTS that underwent surgical decompression.

Section snippets

Materials and methods

In the period January 1997–May 1999, 209 consecutive hands (out of a total of 237 referred) underwent surgery for CTS by the same neurosurgeons in Neurosurgery Unit no. 1 of ‘Azienda Ospedaliera Senese’. The 10 extreme cases of CTS in this series all underwent surgical decompression. They were 9 women and one man, mean age 65 years (range 43–82). The criterion for surgery was intense pain.

Results

After surgery all patients reported disappearance or relief of paraesthesia and numbness. At POST 2 pain disappeared in all hands except one, as testified by the BQ PAIN score which returned to 1 (absence of pain) (Table 1). Almost all showed improved hand dexterity (perhaps also due to resolution of sensory symptoms), but thenar atrophy was unchanged even at 6-month follow-up.

Table 1, Table 2 show patient-oriented and neurophysiological findings before and after surgery. At POST 1, CMAP

Discussion

Previous studies on post-operative outcome of severe CTS (Melvin et al., 1968, Rhoades et al., 1985, Gelberman et al., 1987, Nolan et al., 1992, Finestone et al., 1996, Seror, 1991) have used different criteria for judging severity (clinical, neurophysiological, subjective). The post-operative prognosis of extreme cases of CTS, defined as those in which median sensory and motor responses (distally to the wrist) are not detectable neurophysiologically, is unknown. Only sporadic cases have been

Acknowledgements

We are very grateful to Mrs P. Fineschi of the ASL7 of Siena for contacting all patients for the various follow-ups.

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