A Chilean research team led by Renato J. Verdugo, MD, of the University of Chile in Santiago examined four new studies involving 317 patients with CTS. The studies were randomized, controlled trials identified in a search of all randomized and quasi-randomized controlled trials comparing any surgical and any nonsurgical therapies for CTS. The researchers compared surgical decompression to nonsurgical treatment such as splinting or corticosteroid injections.
“These trials indicate that there is better response from people undergoing surgical treatment compared with splinting, but it is unclear whether there is a better response form surgical treatment compared with steroid injection.”—Renato Verdugo, MD
“Because there is no universally accepted surgical technique for the treatment of this condition, all procedures such as open or endoscopic section of transverse carpal ligament, with or without neurolysis, were to be included,” Dr. Verdugo said. Approximately equal numbers of patients had been assigned to surgery and to nonsurgical treatment. The Cochrane reviewer's primary outcome was improvement at 3 months of follow-up.
“These trials indicate that there is better response from people undergoing surgical treatment compared with splinting, but it is unclear whether there is a better response form surgical treatment compared with steroid injection.”
The authors reported that the pooled estimate for 3-month outcomes favored surgery (RR 1.23, 95% CI 1.04 to 1.46). Two of the trials included 6-month data, which also favored surgery (RR 1.19, 95% CI 1.02 to 1.39). Two trials reported clinical improvement favoring surgery at 12 months after treatment, and one trial that described neurophysiological parameters in both treatment groups also favored surgery.
Dr. Verdugo found that patients who underwent surgery rarely had to return for a second surgery, whereas those who first tried medication or splinting often turned to surgery later. One of the studies included information on surgery's side effects including painful scars, infection, stiffness and discomfort in the wrist. However, the authors found that more than half of the surgical and nonsurgical patients reported having at least one side effect of their treatment.
When surgery was compared with steroid injections in subgroup analysis, neither approach was clearly superior.
“To me it was a surprise to find that steroid injection is not so bad,” Dr. Verdugo told MSKreport.com in an interview. “My concern is that the technique requires at least minimal training because there is the risk of damage to the nerve.”
Translating research into practice: to splint or not to splint
So is there still any role for splinting in treatment of CTS?
Dr. Verdugo thinks there is. “I believe that splinting could be good for 'transient' CTS such as during pregnancy, [which] after labor usually improves.”
Dr. Verdugo would also like to see head-to-head studies of surgery versus steroid injections as well as studies that stratify patients by disease severity. “As we said in the review, it is necessary to know what is better for very severe and also mild CTS.”
For current standard of care, Dr. Verdugo urges not rushing to surgery. He noted that a recent study by Ortiz-Corredor et al who followed carpal tunnel patients for 2 years found that symptoms stayed the same or improved over time in two thirds of patients.2
References
1. Verdugo RJ, Salinas RA, Castillo JL, et al. Surgical versus nonsurgical treatment for carpal tunnel syndrome (Review). Cochrane Lib. 2008. http://www.thecochranelibrary.com.
2. Ortiz-Corredor F, Enríquez F, Díaz-Ruíz J, et al. Natural evolution of carpal tunnel syndrome in untreated patients. Clin Neurophysiol. 2008;119(6):1373-1378.
PubMed: Related Articles