In 1966, George Phalen published his now classic article “The Carpal-Tunnel Syndrome” in The Journal of Bone and Joint Surgery (American Volume)1. Over a seventeen-year period, he diagnosed carpal tunnel syndrome in 654 hands and performed 197 carpal tunnel decompressions. The results were overwhelmingly favorable. He concluded that “sectioning” of the transverse carpal ligament “will almost always relieve the patient’s pain and numbness in the hand, and in many cases will also cure the paralysis of the thenar muscles, which may be present.” Nearly a half century later, Louie et al. validate Phalen’s very favorable findings regarding the efficacy of carpal tunnel release.
Louie and colleagues performed a Level-IV retrospective cohort study of 113 patients who underwent carpal tunnel release at a minimum follow-up of ten years. All data were gathered using a validated questionnaire. The study has several strengths.
First, it provides The Journal’s readers with objective outcome and satisfaction data regarding long-term results of carpal tunnel decompression done by a single surgeon using the same technique. Next, given the number of variables and comorbidities in the series, the statistical methodology was carefully performed. Finally, I commend the authors on their detailed data analysis as it provides clinicians and their patients with long-term objective data about the efficacy of carpal tunnel decompression. Eighty-eight percent of the patients were completely or very satisfied, and the vast majority (87%) had good symptomatic relief, particularly with respect to nocturnal symptoms.
The major shortcoming of this study is the lack of preoperative data supporting the diagnosis of carpal tunnel syndrome. To be eligible for inclusion in the study, patients needed to fulfill two database criteria: (1) they had to have a diagnosis of carpal tunnel syndrome and (2) they had undergone a carpal tunnel release a minimum of ten years earlier. The authors provide no preoperative clinical data as to how the diagnosis of carpal tunnel syndrome was made. The reader must assume that all patients in the cohort had carpal tunnel syndrome. Along similar lines, there is no mention of electrodiagnostic studies. Although such studies are not considered a prerequisite for establishing the diagnosis, they help to support the diagnosis, help to rule out a concomitant peripheral neuropathy or cervical spine radiculopathy, define other sites of median nerve entrapment, and can be repeated postoperatively if recovery has failed to occur. Recently, Faour-Martin et al.2 completed a study that assessed improvements in clinical, functional, and electrodiagnostic parameters at a mean of 10.47 years after carpal tunnel release. Using the Levine-Katz outcome instrument, those authors, like Louie et al., found significant functional and symptomatic improvement in 115 patients.
The authors carefully evaluated the impact of comorbidities on outcome following surgery. Not surprisingly, the presence of an increasing number of comorbidities directly correlated with less symptomatic, functional, and clinical improvement. Although a minor criticism, it would have been useful to have information regarding how cervical spondylosis as a “double crush” may negatively impact outcome3.
Finally, I was surprised to learn that the fifty to fifty-nine-year age group (twenty-three patients) reported worse function, satisfaction, and symptoms compared with the younger and older age groups. It is generally held that patient satisfaction is less predictable in the elderly4; nevertheless, most surgeons agree that it is still a worthwhile procedure in this age group. I suspect this finding is a reflection of the small number of patients in this group.
In conclusion, the authors provide convincing outcome evidence confirming the observation by Phalen1 nearly fifty years ago that open carpal tunnel decompression provides a high level of patient satisfaction and symptomatic relief regardless of age, sex, or comorbidities.