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Surgical treatment options for carpal tunnel syndrome

There is no strong evidence for the replacement of standard open carpal tunnel release (OCTR) by alternative surgical procedures for the treatment of carpal tunnel syndrome. The decision to apply special, minimally invasive operations instead of standard OCTR seems to be guided by the surgeon's and patient's preferences.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Carpal tunnel syndrome: When is surgery an option and when is it necessary?

Most people with carpal tunnel syndrome only consider having surgery if other treatments cannot provide enough relief. Surgery can help relieve symptoms or make them go away for good, but it is not without risks.In carpal tunnel syndrome the median nerve, which runs through the carpal tunnel in your wrist, is compressed. This can cause pain, tingling sensations and numbness, and limit your range of motion. Surgical treatment involves severing the flexor retinaculum to reduce pressure on the median nerve. This is one of the most commonly performed surgical procedures in Germany.Surgery can eliminate symptoms for good, but it is not always necessary. Another kind of treatment is usually chosen, especially if symptoms have just started. Immediate surgery is only needed in very rare cases of acute carpal tunnel syndrome.Surgery to treat carpal tunnel syndrome is usually referred to as “carpal tunnel release.” There are two main types:Open carpal tunnel release: A cut is made on the inside of the wrist. After that the flexor retinaculum is severed.Endoscopic carpal tunnel release: This procedure requires first making a cut on your palm and your wrist. A very small camera (called an “endoscope”) is inserted through one of the cuts to monitor the procedure. An instrument used for cutting through the flexor retinaculum is inserted through the other cut. Another technique involves using just one small cut in the wrist.These two types are equally good at relieving symptoms and carry similar risks. Recovery times are often a little shorter after endoscopic procedures.This procedure is most commonly done at a day clinic but can also be performed in a hospital. Usually only a local anesthetic is needed to numb the hand or arm, but a brief regional or general anesthetic might also be used.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: November 5, 2014

Oral steroids, splinting, ultrasound, yoga and wrist mobilisation provide short‐term relief from carpal tunnel syndrome, but other non‐surgical methods have not been shown to help.

Carpal tunnel syndrome is caused by compression of the median nerve at the wrist, leading to mild to severe pain and pins and needles in the hand. Other Cochrane reviews show benefit from nerve decompression surgery and steroids. This review of other non‐surgical treatments found some evidence of short‐term benefit from oral steroids, splinting/hand braces, ultrasound, yoga and carpal bone mobilisation (movement of the bones and tissues in the wrist), and insulin and steroid injections for people who also had diabetes. Evidence on ergonomic keyboards and vitamin B6 is unclear, while trials so far have not shown benefit from diuretics, non‐steroidal anti‐inflammatory drugs, magnets, laser acupuncture, exercise or chiropractic.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Splinting for carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a condition where one of two main nerves in the wrist is compressed, which can lead to pain in the hand, wrist and sometimes arm, and numbness and tingling in the thumb, index and long finger. CTS is more common in women and older age groups. Many people undergo surgery to treat this condition, though sometimes other non‐surgical treatments, such as splinting, are offered. Splinting involves immobilisation of the wrist with a device that is worn over the wrist, which usually leaves the fingers and thumb free to move. We searched for study reports and found 19 randomised or quasi‐randomised controlled trials including 1190 participants overall that assessed the safety and benefit of splinting for people with CTS. The risk of bias of studies was low in some studies and unclear or high in others. One low quality study suggests that splinting at night leads to more overall improvement in the short term when compared to no treatment, but we cannot say from the evidence whether one splint design or wearing regimen is more effective than another, nor can we say that splinting is more effective than other non‐surgical interventions for CTS (for example exercises, oral steroids). Nine trials measured adverse effects of splinting and all found either no or few participants reported discomfort or swelling due to splinting. More research is needed to find out how effective and safe splinting is for people with carpal tunnel syndrome, particularly in the long term.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

This study found large variability in the use of some common procedures that cannot be explained by differences in local need and may reflect uncertainty about appropriate use. This may help identify procedures that could be reassessed for disinvestment.

Health Services and Delivery Research - NIHR Journals Library.

Version: April 2015
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Endoscopic release for carpal tunnel syndrome

We reviewed the evidence about how safe and effective endoscopic carpal tunnel release (ECTR) is, compared to any other type of surgery for carpal tunnel syndrome (CTS).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Rehabilitation following carpal tunnel release

Carpal tunnel syndrome (CTS) is a condition in which a nerve that runs through a bony and fibrous tunnel in the wrist is compressed. This leads to pain, numbness and tingling in the hand, sometimes extending into the forearm. At advanced stages, some people with CTS have weakness and muscle wasting in the hand. CTS is more common in women and individuals with certain risk factors, such as diabetes, obesity, arthritis, older age, working in certain occupations, and previous wrist fracture. Many people undergo surgery to reduce pressure on the nerve, to lessen pain, and improve sensation and hand function. Sometimes individuals receive rehabilitation following CTS surgery. Rehabilitation treatments are believed to speed up recovery and manage pain or symptoms from the surgery itself. This is the first update of a review first published in 2013.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials

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.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

A systematic review of conservative treatment of carpal tunnel syndrome

The authors concluded that there is strong evidence that local and oral steroids are effective, moderate evidence that vitamin B6 is ineffective and splints are effective, and limited or conflicting evidence about the other treatments. Much of the review was well-conducted, but the comparators were diverse, there was a lack of clarity about grading the evidence, and the conclusions appear overoptimistic given the limited data.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2007

Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? A systematic review

This review concluded that both surgical and conservative interventions had treatment benefit in the management of carpal tunnel syndrome. Surgical treatment had a superior benefit in symptoms and function at six and twelve months. These conclusion should be interpreted with caution given the risk of publication and language bias and limitations in review methods.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2011

Surgical techniques and return to work following carpal tunnel release: a systematic review and meta-analysis

The authors concluded that minimally invasive carpel tunnel surgery may have allowed patients to return to their previous occupation sooner than open carpel tunnel release. The authors’ conclusions reflect the limited evidence presented but the potential for missing studies should be considered.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2011

A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression

Controversy exists regarding the benefit of endoscopic carpal tunnel release versus open carpal tunnel release in terms of grip/pinch strength, scar tenderness, pain, return to work, reversible/irreversible nerve damage, and adverse effects. Although a number of randomized controlled trials and systematic reviews have been published on the subject, to date, no large definitive randomized controlled trial or meta-analysis has been performed comparing endoscopic to open carpal tunnel release. This meta-analysis was undertaken to address the effectiveness of endoscopic carpal tunnel release relative to open carpal tunnel release. Key outcome measures from 13 randomized controlled trials were extracted and statistically combined. Heterogeneity was observed in three of the outcomes (i.e., grip strength, pain, and return to work), but the causes of heterogeneity could not be explained because of insufficient detail in the reported studies. Using the Jadad et al. scale, nine of 13 studies were of low methodologic quality. The effect sizes were compared between the studies that were rated as high quality and the studies that were rated as low quality on the Jadad et al. scale. Similarly, the studies that were rated as high quality on the Gerritsen et al. scale were compared with those that were rated as low quality. No clinically significant difference in effect sizes was apparent between studies of high and low methodologic quality. This meta-analysis supports the conclusion that endoscopic carpal tunnel release is favored over the open carpal tunnel release in terms of a reduction in scar tenderness and increase in grip and pinch strength at a 12-week follow-up. With regard to symptom relief and return to work, the data are inconclusive. Irreversible nerve damage is uncommon in either technique; however, there is an increased susceptibility to reversible nerve injury that is three times as likely to occur with endoscopic carpal tunnel release than with open carpal tunnel release.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2004

Effectiveness and safety of endoscopic versus open carpal tunnel decompression

The authors concluded that endoscopic carpal tunnel release and open carpal tunnel release produced similar relief of symptoms, but endoscopic surgery was safer, and had better recovery of function and earlier return to work. In light of important bias identified in several key trials, the authors' conclusions should not be considered reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

Accuracy of in-office nerve conduction studies for median neuropathy: a meta-analysis

This review concluded that in-office nerve conduction measurement detected median neuropathy with clinically relevant accuracy with similar performance to inter-examiner agreement within a traditional electrodiagnostic laboratory. This conclusion is unlikely to be reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2011

Randomised controlled trial of Tumour necrosis factor inhibitors Against Combination Intensive Therapy with conventional disease-modifying antirheumatic drugs in established rheumatoid arthritis: the TACIT trial and associated systematic reviews

This study found that people with active rheumatoid arthritis eligible to start biologic treatment in England achieve similar clinical benefits at a lower cost from starting combinations of conventional disease modifying anti-rheumatic drugs.

Health Technology Assessment - NIHR Journals Library.

Version: October 2014

Psoriasis: Assessment and Management of Psoriasis

Psoriasis is a common, chronic disease, which for many people, is associated with profound functional, psychological and social morbidity and important comorbidities. Effective treatments are available. Some treatments are expensive; all require appropriate monitoring and some may only be accessed in specialist care settings. Evidence indicates that a substantial proportion of people with psoriasis are currently dissatisfied with their treatment.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: October 2012
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Major Trauma: Assessment and Initial Management

This guideline provides guidance on the assessment and management of major trauma, including resuscitation following major blood loss associated with trauma. For the purposes of this guideline, major trauma is defined as an injury or a combination of injuries that are life-threatening and could be life changing because it may result in long-term disability. This guideline covers both the pre-hospital and immediate hospital care of major trauma patients but does not include any management after definitive lifesaving intervention. It has been developed for health practitioners and professionals, patients and carers and commissioners of health services.

NICE Guideline - National Clinical Guideline Centre (UK).

Version: February 2016

Surgical Site Infection: Prevention and Treatment of Surgical Site Infection

Infections that occur in the wound created by an invasive surgical procedure are generally referred to as surgical site infections (SSIs). SSIs are one of the most important causes of healthcare-associated infections (HCAIs). A prevalence survey undertaken in 2006 suggested that approximately 8% of patients in hospital in the UK have an HCAI. SSIs accounted for 14% of these infections and nearly 5% of patients who had undergone a surgical procedure were found to have developed an SSI. However, prevalence studies tend to underestimate SSI because many of these infections occur after the patient has been discharged from hospital.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: October 2008
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Antenatal Care: Routine Care for the Healthy Pregnant Woman

The original antenatal care guideline was published by NICE in 2003. Since then a number of important pieces of evidence have become available, particularly concerning gestational diabetes, haemoglobinopathy and ultrasound, so that the update was initiated. This update has also provided an opportunity to look at a number of aspects of antenatal care: the development of a method to assess women for whom additional care is necessary (the ‘antenatal assessment tool’), information giving to women, lifestyle (vitamin D supplementation, alcohol consumption), screening for the baby (use of ultrasound for gestational age assessment and screening for fetal abnormalities, methods for determining normal fetal growth, placenta praevia), and screening for the mother (haemoglobinopathy screening, gestational diabetes, pre-eclampsia and preterm labour, chlamydia).

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: March 2008

What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis

The study found that the process of referral from primary to specialist non-emergency care is complex, with multiple elements that impact on intervention outcomes and local area applicability. Any interventions that aim to change referral practice must address practitioner, patient and situational factors. The findings apply especially to the UK NHS, whose remit includes all of these factors and issues.

Health Services and Delivery Research - NIHR Journals Library.

Version: May 2015
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