• 
• 

Three Part Question

[In adults diagnosed with Carpel Tunnel syndrome] is [non surgical intervention better then surgical intervention] to [reduce pain and improve hand functions]?

Clinical Scenario

You are the specialty emergency trainee doctor working in the emergency department. The next patient is a 42 years old female who is referred by her General practitioner with confirmed diagnosis of Carpal tunnel syndrome since last six months, for symptom management especially pain. She complained of pain, tingling and numbness in the left hand which gets worse at night. She mentioned about disturbed sleep due to aggravating symptoms. She was concerned because she was unable to return to work and look after her family. There was no significant past medical history. On examination there was sensory impairment in the first three digits, Phalen sign was positive. You discussed with the orthopedic Specialty registrar on call who requested to discharge the patient on oral analgesia and refer to the orthopaedic outpatient clinic for further evaluation for surgical intervention. You wonder whether non surgical intervention is better than surgical.

Search Strategy

• OVID Medline 1946 – February Week 1 2014
• Cochrane database
• Google search

[exp Carpal Tunnel Syndrome/ OR Median entrapment neuropathy.mp.] AND [exp Splints/ OR exp Physical Therapy Modalities/ OR exp Analgesics/ OR Non surgical intervention.mp.] OR [exp Steroids/ OR Physiotherapy.mp. OR Pain killers.mp.] AND [Carpal tunnel release.mp. OR Carpal tunnel surgery.mp. OR Surgical intervention.mp.] AND Limit 16 to (English language and humans and "all adult (19 plus years)

Search Outcome

The Medline produced 50 papers of which 7 were relevant. The search also identified a relevant Cochrane review which will be discussed in the comments section. Google scholar did not identify any new articles.

Five relevant papers have been critically appraised.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Jarvik JG et al 2009 USA	116 patients above 18 years of age presenting between October 2002 to May 2007 from 8 centers with diagnosis of carpel tunnel syndrome greater than 2 weeks. Confirmed by electro diagnostic studies. In absence of electro diagnostic criteria, positive in night pain and flick test, English language proficient, were included Excluded if previous treatment with Carpel Tunnel syndrome release surgery, severe thenar muscle atrophy 57 patients were allocated to surgery, 59 were allocated to non-surgical treatment. 207 patients refused to participate in random control trial but enrolled in observational group	Single blinded parallel group randomized control trial, Level 2	All patients were re-accessed at 6 weeks, 3 month, 6 months, 9 months and at 12 months after randomization. Primary outcome measure was 9 item functional status scale of Carpel Tunnel syndrome assessment questionnaire (CTSAQ function scale). Measured from 1 (no functional limitations or symptoms) to 5 (extreme limitation or symptom severity) Secondary outcome measure was 11 item symptom severity status scale of Carpel Tunnel syndrome assessment questionnaire (CTSAQ symptom scale).measured from 0 (no pain or interference) to 10 (extreme pain or interference) All patients also had MRI.	At both 6 and 12 months more patients in the surgical group as compared to the non-surgical group had a successful outcome (improvement of 0•50 points or 30% on the CTSAQ function scale) At 6 months the score was (0•46 points) improved for the surgical group in CTSAQ function (95% CI 0•20 to 0•72, p=0•0006) and for CTSAQ symptom the score was 0•42 points improved in the surgical group than in the non-surgical group (95% CI 0•07 to 0.77, p=0•0181) At year 1 the score was 0•40 points improved in the surgical group than in the non-surgical group, adjusting for baseline function and treatment site (95% CI 0•11 to 0.70, p=0•0081) and for CTSAQ symptom the score was 0•34 points improved in the surgical group than in the non-surgical group (95% CI 0•02 to 0.65, p=0•0357)	1. Selection bias due to inclusion of English language proficient patients. 2. There was large number of patients missing MRI data, which limited the power of the study to access the ability of MRI to predict outcome. 3. Surgical techniques were not standardized. 4. Allowed cross over. 5. Baseline sign and symptoms were not mentioned. 6. Lack of appropriate blinding
Gerritsen AA et al 2003 Netherland	176 patients with confirmed carpel tunnel syndrome were recruited between October 1998 to April 2000, 78 patients had wrist splint during night for at least 6 weeks and 86 patients had surgery. Clinically and electrophysiological confirmed patients of 18 years or older; and with the ability to complete the questionnaires (in Dutch) were included. Exclusion criteria was patients with under lying causes of Carpel Tunnel syndrome, previous wrist trauma and release surgery, severe thenar muscle atrophy, language barrier	Randomized control trial, Level 2	After randomization patients were assessed for primary outcomes at 1, 3, 6, 12 and 18 months and secondary outcomes at 3, 6, 12 and 18 months by using a six-point ordinal scale.	Success rate at; • 3rd month: 80% for the surgical group compared to 54% for splinting group(95% CI 12 to 40, p=0.001) • 6th month: 94% for the surgical group compared to 68% for splinting group(95% CI 14 to 37, p=0.001) • 12th month: 92% for the surgical group compared to 72% for splinting group(95% CI 8 to 31, p=0.002) • 18th month: 90% for the surgical group compared to 75% for splinting group(95% CI 3 to 27, p=0.002)	1. Allowed cross over. 2. Selection bias due to inclusion of Dutch language proficient patients. 3. Lack of appropriate blinding 4. No power calculation. 5. Baseline sign and symptoms were not mentioned.
Qiyun Shi and Joy C MacDermid 2011 Canada	Literature searched from four databases over a period from 1980 to June 2010 and included studies available in English language, with patients diagnosed with Carpel Tunnel syndrome and prospective control trial design which compared any of the surgical and non surgical interventions. Studies published before 1970, not providing data on intervention effectiveness and only compared two surgical or two non surgical interventions were excluded. 712 participants in total.	Systematic review including 5 randomized control trials and 2 control trials, Level1	Jadad score [3] and structured effectiveness quality evaluation scale was used to score study quality. 4 studies were ranked high quality studies. Patient Self reported scales, researcher assessed subjective impairments, and muscle strength and electrophysiological studies were used to access outcomes. 5 studies used functional and symptomatic scale questionnaires. 4 studies included scales for disease specific hand functions	No statistical difference at 3 months was identified. At 6 months and 12 months treatment benefit from surgical intervention was identified (95% CI 0.22, 0.47) and (95% CI 0.15, 0.55) respectively. Surgery was found to be superior to the conservative management regarding the improvement of electrophysiological study.	Small sample size
Demirci et al 2002 Turkey	90 patients with diagnosed of carpel Tunnel syndrome for more than 6 months and confirmed with electro diagnostic studies. Exclusion criteria; Previous steroid injection, open carpel tunnel release surgery, distal radial fracture and under lying Carpel tunnel disease. 44 patients had open Carpel Tunnel release and 46 had two dose steroid injection.	Comparative cohort study Level 3	Used Boston Questionnaire, a self administered questionnaire for the assessment of severity of symptoms and functional status in patients with carpel tunnel syndrome along with electrophysiological evaluation before any treatment and prescribed follow up interval	Both groups showed significant improvement in symptomatic and functional status scores.	1. Small sample size. 2. Non random group allocation. 3. No demographic data. 4. Difficult to extract results pre and post intervention

Clinical Bottom Line

In conclusion, both surgical and non-surgical interventions are beneficial in the management of Carpel Tunnel Syndrome. Surgical treatment seems superior to non-surgical treatment especially in the long term but there was no evidence to support any significant difference in the outcome of both surgical and non-surgical treatment in the short term. It is worth considering that Cochrane review [11] of surgical versus non-surgical treatment for Carpel Tunnel Syndrome also concluded the above statement.

References

1. Jarvik JG, Comstock BA, Kliot M, Turner JA, Chan L, Heagerty PJ, Hollingworth W, Kerrigan CL, Deyo RA Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial Lancet 2009, 374(9695):1074-81
2. Gerritsen AA, de Vet HC, Scholten RJ, Bertelsmann FW, de Krom MC, Bouter LM Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial JAMA 2002, 288(10):1245-1251
3. Qiyun Shi and Joy C MacDermid Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? A systematic review J Orthop Surg Res. 2011 Apr 11;6:17. doi: 10.1186/1749-799X-6-17
4. Demirci S, Kutluhan S, Koyuncuoglu HR, Kerman M, Heybeli N, Akkus S,et al Comparison of open carpal tunnel release and local steroidtreatment outcomes in idiopathic carpal tunnel syndrome Rheumatol Int 2002, 22(1):33-37