Carpal tunnel syndrome affects as many as close to 2 million people in the United States. Between 300,000 – 500,000 operations are performed annually, at a total cost of $2 billion. All surgical approaches for primary treatment involve dividing the transverse carpal ligament by one or another technique. However, there continues to be discussion about the role of adjunctive direct neurolysis, either internal or external, in the treatment of primary CTS. The authors therefore conducted a meta-analysis as part of a report addressing "Work-Related Musculoskeletal Disorders of the Upper Extremity" for the Agency for Healthcare Research and Quality. The report was conducted by reviewing 17 databases for references to carpal tunnel syndrome, through 2001. Studies involving some form of adjunctive neurolysis, either external, internal, or epineurotomy were compared with controls of those studies involving only open carpal tunnel release. Global outcomes were compared statistically. Eight studies were found which satisfied the criteria for inclusion. These included six blinded trials, one non-randomized trial, and one retrospective review.
The results indicated that there was a statistically significant negative impact on global outcome measures in patients receiving neurolysis in addition to CTR. In the studies highlighted, 12% of the patients receiving direct neurolysis had a less favorable outcome than the group having CTR alone. The authors point out that the studies were generally of poor quality with statistical flaws, such as attrition, bilaterality that was not selected out, and retrospective design. Yet, their analysis of those errors does not make it likely that the negative impact of neurolysis/epineurotomy would have been lessened by their correction. The authors are also wise to point out that the results do not necessarily pertain to all CTR operations, such as revisions or cases with unusual anatomic findings, such as dense perineural fibrosis or anatomic variants causing compression. In those cases, neurolysis and epineurotomy probably still have a role. In routine primary CTS, however, this report supports earlier studies, which also found no benefit of internal and external neurolysis in carpal tunnel releases.
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Plastic & Reconstructive Surgery 112: 983-990, 2003.