To The Editor:
"Open Carpal Tunnel Release Is the Preferred Method of Surgical Treatment for Carpal Tunnel Syndrome," a review article in Evidence-Based Orthopaedics (2002;84:1489), consisting of a structured abstract and commentary on a systematic review by Gerritsen et al.
1 , does not in any way support its title and/or the conclusion reached. If anything, it supports the opposite view. The Main Results section of the abstract states that four of the trials in the systematic review "showed an earlier return to work or to the activities of daily living for patients who had had endoscopic carpal tunnel release in comparison with those who had had open carpal tunnel release."
Review articles such as this one are quite misleading. Furthermore, additional misleading statements were made in the commentary by Dr. Robert Szabo. He stated that visualization is poor or absent in endoscopic carpal tunnel release and he reached the same conclusion-that the preferred surgical treatment remains open carpal tunnel release.
Here at The Hand Center of Western Connecticut, where our combined experience in surgery of the hand exceeds forty years, we have offered endoscopic carpal tunnel release with use of a single portal to virtually all of our patients with carpal tunnel syndrome since 1992. A few have had an open release (performed here or elsewhere before they were referred to us) and have subsequently developed carpal tunnel syndrome in the contralateral hand, which we treated with an endoscopic release. We have yet to encounter a single patient who preferred the open procedure to the endoscopic one.
I fully agree that the ultimate outcome of the two procedures is the same, but the process leading to the outcome dramatically differs between them.
I wish to end my comments with an anecdote about a typical patient who presented to The Hand Center following an open carpal tunnel release in the dominant hand for severe carpal tunnel syndrome, which was present bilaterally. Her reason for coming to our clinic was the severe pain and lack of relief of symptoms that she experienced following the open procedure. We assured her that she would ultimately do well, and we subsequently performed endoscopic surgery on the contralateral hand. Five and one-half months following the open procedure, she continued to have palmar pain and tenderness in the dominant hand and a grip strength of 53 lb (24 kg). Six weeks following the endoscopic procedure, she not only had no pain or paresthesias in her nondominant hand but she also had a grip strength of 78 lb (35 kg). Her subjective analysis of the two procedures was that the endoscopic approach was far less uncomfortable and the recovery far easier for her as a patient.
While it might be tempting to look at data in the abstract, I think that we as physicians all have an obligation to seek the opinion of our patients and to listen to their comments when we offer them invasive surgical procedures. If we do so, we will discover that the less invasive procedure is, for them, far more preferable.
J.G. Wright replies:
I thank Dr. Brown for his comments and interest in the Evidence-Based Orthopaedics abstract and summary of the article by Gerritsen et al.
1 . He disagreed with the conclusion of the systematic review, which supported open release as the preferred surgical treatment for carpal tunnel syndrome.
The intent of the Evidence-Based Orthopaedics section of
The Journal is to provide surgeons with current high-quality evidence that can be used in choosing the best treatments for their patients. Systematic reviews are summaries of multiple randomized trials. Although not without methodological challenges, a meta-analysis is a study in which results from multiple randomized trials are combined to address a specific clinical question. Because the results and conclusions from the trials included in the systematic review by Gerritsen et al. varied (a phenomenon called heterogeneity), the authors did not combine these together but simply reported the conflicting study results.
Dr. Brown stated that the review "does not in any way support its title and/or the conclusion reached." Of the seven trials comparing endoscopic carpal tunnel release with open carpal tunnel release, three showed no difference in time to return to work and four showed an earlier return to work in patients who had had the endoscopic procedure. None of the seven randomized trials demonstrated any short or long-term difference in the clinical outcome of endoscopic compared with open carpal tunnel release. As acknowledged in the abstract, the literature provides no clear answer to the question of which is the preferred treatment. Thus, in the absence of a clear benefit and considering the special equipment and training required to perform endoscopic release, the conclusion of the systematic review, which is reflected in the title of the abstract, supports standard therapy.
Dr. Brown stated that "review articles such as this one are quite misleading." However, he provided no specific discussion of how systematic reviews are misleading.
Dr. Brown clearly has firm beliefs about the benefits of endoscopic carpal tunnel release. The surgical literature at this time, however, does not unequivocally support his opinions. The intent of evidence-based practice is to move beyond personal opinion and base treatment choices on the findings of well-performed clinical trials.