The Journal of Bone and Joint Surgery

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Commentary & Perspective

Commentary & Perspective on
"Functional Tests to Quantify Recovery Following Carpal Tunnel Release"
by Robert G. Radwin, PhD, et al.

Commentary & Perspective by
Lana Kang, MD, and Andrew J. Weiland, MD*,
Hospital for Special Surgery, New York, NY

Updated February 15, 2007

Carpal tunnel syndrome is a very prevalent entity. It is seen in a vastly diverse population of patients and is treated by a variety of medical professionals. Its pervasiveness has stimulated tremendous amounts of academically and commercially supported research efforts to explore its etiology, pathophysiology, associated risks, natural history, economic impact, and various responses to treatment.

The surgical treatment of carpal tunnel syndrome has evolved to a point at which it currently can be expected to be a minimally invasive procedure that is associated with minor morbidity, rapid recovery, and minimal scarring. Surgically treated carpal tunnel syndrome carries an excellent prognosis, especially when the disorder has been diagnosed correctly and treated early. Even when surgery is not performed until all other nonoperative forms of treatment have been exhausted, the success rate of surgery is usually greater than 90%, with several studies reporting a success rate of 95% or better^1-3.

Nevertheless, much about the condition remains unexplained. For example, it is unclear why a local injection of corticosteroid results in relief of symptoms in an unpredictable proportion of patients and why, if carpal tunnel syndrome is indeed a mechanical compressive phenomenon, this form of treatment would ever result in a complete resolution of symptoms even in a fraction of patients. It is also a well-known but unexplained observation that, while neuroconductive and electrophysiologic testing can be an indispensable diagnostic aid, many patients who are clinically diagnosed and subsequently successfully treated for carpal tunnel syndrome have normal baseline nerve conduction and electromyographic parameters⁴.

Radwin et al. try to test the sensitivity and clinical applicability of two manually based tools. They also compare them against another well-accepted outcome instrument, the Levine carpal tunnel questionnaire⁵. The objective of the investigation complies with the heightened emphasis in the medical and orthopaedic community to evaluate and treat diseases in terms of validated outcome instruments. What is different about this study is that it revisits the relevance of so-called "objective" data to measure and define "functional outcome." By so doing, the authors offer a way to include clinician-derived (objective) data in developing a more complete and accurate assessment of functional outcome, rather than relying solely on subjective tests, such as the Levine questionnaire.

It is highly unlikely that the results of this study will have any bearing on the way the typical case of carpal tunnel syndrome is diagnosed and treated—why should it, given the high rate of success achieved with the use of current methods? Furthermore, the results with surgery are promising, even for those challenging cases that were once believed to be less predictable (e.g., elderly patients, patients with advanced disease, and patients receiving Worker's Compensation)^6,7. What this investigation may lead to is an improved method of understanding and subsequent treatment of the 5% or so of patients who do not have a satisfactory result after treatment. The authors should place greater emphasis on the potential capability of their objective tools to create a more sophisticated and individually tailored rehabilitation program with task-specific protocols that address a patient's specific psychomotor and sensory deficits. The ability of these tests to do so would offer a great advantage over the patient-derived questionnaires, which, although informative about the effectiveness of treatment, can be time-consuming and burdensome to the patient and do not guide the next step in management after treatment has been delivered.

The authors propose that their motor and sensory tools could permit a quantitative evaluation of the capacity to return to work. Conversely, these tests could lead to a better way to determine whether a worker's inability to return to work is indeed quantifiable and financially justifiable. These issues have substantial socioeconomic impact with regard to insurance and Worker's Compensation claims that result in time away from work and loss of income. On a more practical level, the authors must demonstrate that these psychomotor and sensory tests are practical in the everyday clinical setting, and that they are cost efficient, time efficient, user friendly, and easy to administer.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Bradley MP, Hayes EP, Weiss AP, Akelman E. A prospective study of outcome following mini-open carpal tunnel release. Hand Surg. 2003;8:59-63.
2. Chow JC, Hantes ME. Endoscopic carpal tunnel release: thirteen years' experience with the Chow technique. J Hand Surg [Am]. 2002;27:1011-8.
3. Klein RD, Kotsis SV, Chung KC. Open carpal tunnel release using a 1-centimeter incision: technique and outcomes for 104 patients. Plast Reconstr Surg. 2003;111:1616-22.
4. Kitsis CK, Savvidou O, Alam A, Cherry RJ. Carpal tunnel syndrome despite negative neurophysiological studies. Acta Orthop Belg. 2002;68:135-40.
5. Levine DW, Simmons BP, Koris MJ, Daltroy LH, Hohl GG, Fossel AH, Katz JN. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993;75:1585-92.
6. Leit ME, Weiser RW, Tomaino MM. Patient-reported outcome after carpal tunnel release for advanced disease: a prospective and longitudinal assessment in patients older than age 70. J Hand Surg [Am]. 2004;29:379-83.
7. Manktelow RT, Binhammer P, Tomat LR, Bril V, Szalai JP. Carpal tunnel syndrome: cross-sectional and outcome study in Ontario workers. J Hand Surg [Am]. 2004;29:307-17.