Incidence of Recurrent and Persistent Carpal Tunnel Syndrome following Open Transverse Carpal Ligament Release

authors:

avatar Parviz Yazdanpanah 1 , * , avatar Hamidreza Mohamadi 2 , avatar Ali Mousavizadeh 3 , avatar Ali Sahuli-Tanha 4

Department of Physical Medicine and Rehabilitation, Yasuj University of Medical Sciences, Yasuj, Iran
Department of Orthopedics, Yasuj University of Medical Sciences, Yasuj, Iran
Department of Statistics and Epidemiology, Faculty of Public Health, Yasuj University of Medical Sciences, Yasuj, Iran
Student Research Committee, Yasuj University of Medical Sciences, Yasuj, Iran
Zahedan Journal of Research in Medical Sciences: Vol.17, issue 1; e1923
published online: December 24, 2014
article type: Research Article
received: July 4, 2013
accepted: July 23, 2013

how to cite: Yazdanpanah P, Mohamadi H, Mousavizadeh A, Sahuli-Tanha A. Incidence of Recurrent and Persistent Carpal Tunnel Syndrome following Open Transverse Carpal Ligament Release. Zahedan J Res Med Sci. 2015;17(1):e1923. 

Abstract

Background:

Carpal tunnel syndrome is entrapment of the median nerve in carpal tunnel of the wrist. In severe cases of carpal tunnel syndrome, or those refractory to conservative treatment, surgery is performed. The main aim of this research was to determine the incidence of recurrent and persistent rates of carpal tunnel syndrome following open surgery.

Materials and Methods:

This descriptive cross sectional study was performed on 105 patients having open carpal tunnel release in the range of 5 to 60 months ago. These cases were operated at Shahid Beheshti hospital in Yasuj, Iran. Assessment of carpal tunnel syndrome after open surgical release of the median nerve was done by electrodiagnostic studies and MRI. If symptoms of carpal tunnel syndrome maintain after surgery, this condition is persistent and if reappearance of the syndrome 3 months or more following surgery this is recurrent. In cases of observing changes from severe to lower stages of the disease in electrodiagnostic studies, treatment is considered successful.

Results:

All of 58.1% of patients had right severe carpal tunnel syndrome and 41.9 % had left severe carpal tunnel syndrome prior to surgery. The incidence of recurrent and persistent carpal tunnel syndrome following open transverse carpal release was 12.4% and 10.4%, respectively.

Conclusion:

The incidence of persistent and recurrent rates of carpal tunnel syndrome following open transverse carpal release was higher than the expected rate. These rates were dependant to the appropriate patient, the correct diagnosis and duration of symptoms before surgery.

Results

One hundred-five cases with carpal tunnel syndrome operation history were selected randomly from client referred to Shahid Beheshti hospital of Yasuj Medical University, Iran.

All of 96 (91.5%) of participants in the study were females, and 9 (8.5%) of them males. The age ranges of patients were 24 to 88 years, with average of 50.97 years, and the highest-frequency between 38 and 64 years. In view of body mass index (BMI) by kg/m2, the range value was between 17.3 to 42.9 with average of 27.6 and the highest frequency between 23.2 and 32.1. In the total cases, the shortest period of post-operative referral was 5 months, and the longest 60 months, with average of 17.7 months, and the highest frequency was between 15.1 to 19.3 months, with 95% confidence interval.

Of all patients in study that had open surgical operation history for release transverse carpal ligament of wrist, 58.1% and 41.9% were suffering from severe CTS of right and left hand before operation respectively and in other patients despite of complaint from symptom. The 77.2% were in the normal group, based on normal electrodiagnostic or mild entrapment of the median nerve. Thirteen patients were in recurrence condition at least for 3 months after open surgical operation of transverse carpal ligament (recurrence incidence equal to 12.4%). No immediate post-operative clinical recovery or reappearing of symptoms less than three months after operation was observed in 11, which are equal to 10.4% persistent rate (Table 1).

Table 1.

Frequency distribution of the patient's post-operative condition

Post-operative conditionFrequencyPercentCumulative percent
Normal8177.277.2
Persistent1110.487.6
Recurrent1312.4100
Total105100

In 4 patients MRI was reported absolutely normal and in 4 other cases edema around the median nerve was observed. Other cases were absolutely normal.

Discussion

According our finding, incidence of recurrent and persistent rates of CTS after open transverse carpal ligament release was 12.4% and 10.4% respectively. In previous studies, using endoscopic or open surgical procedures, the incidence of the 2 complications are very different [11-13].

Diagnosis and appropriate treatment of complications related to carpal tunnel release facilitate early appropriate treatment which usually diminishes disability.

In a study by Botte et al. the recurrence rate of CTS is to occur in 0% to 19% of patients following carpal tunnel release, with up to 12% requiring re-exploration. Common causes of recurrent CTS are incomplete release of transverse carpal release, fibrous proliferation, or recurrent tenosynovitis [12].

In a study by Raimbeau, the recurrence rate of CTS following surgery varies from 0.3% to 12% [11]. In the study of Concannon et al. there seems to be a statistically higher incidence of recurrent CTS after endoscopic release compared with the traditional open carpal release [13].

In a study by Erbayraktar et al. the results of open surgical operation of CTS without removing sheath of the median nerve was better in comparison to endoscopic surgery [14]. In different research studies, the recurrence rate of CTS, using endoscopic surgical method has been reported 0.5% to 6% [15, 16].

In a study by Omer, while surgery of transverse carpal ligament is usually successful, 7-30% of patients will have either persistent or recurring symptoms [17]. Although most outcomes of transverse carpal release are positive, CTS symptoms persist or recur in 7% to 20% of surgical releases, and reoperation is required in approximately 5% of cases [18].

In the present research, the recurrence rate and persistent of CTS symptoms were high, the reasons for which could be late referral of patients, insufficient removal of transverse carpal ligament, surgeons’experience and differential diagnosis coupled which with the syndrome. General complications have also been discussed including recurrent scar formation which is probably the most commonly encountered complication following carpal tunnel release [19].

In 50% of the patients of the present research, edema around the median nerve was reported in wrist MRI, a finding which is in consistency with a study by Taghizadeh et al. in which median nerve edema has been reported in 70% of cases after surgical operation to release transverse carpal ligament followed by the recurrence of syndrome [20]. In other research studies, circumferential fibrosis around the median nerve has been the most prevalent reason for recurrence and persistent symptoms of CTS, which is usually specified after surgical re-operation or in MRI by an experienced radiologist [16, 21]. In this research, about 91% of the cases were females, showing the high prevalence of CTS among women, which is inconsistency with other research studies [21, 22].

The mean age of patients was 50.97 years, with the highest frequency between 37.85 and 64 years which is also in consistency to other research studies such as [23], with respect to the prevalence of the disease in the middle ages of life. The prevalence of CTS in the right hand (dominant hand) is often higher than left hand, which was in consistency with other research studies such as Shapiro and Preston [22].

No recovery was reported in 11 patients who were all females, which were placed in the residual group. The reasons for this status included late referral of the above mentioned patients, no elimination of severity factors of the syndrome such as job related factors, presence or absence of experienced surgeon, economic factors and etc.

Incidence of persistent and recurrent rates of CTS following open transverse carpal release was high. These rates were dependant to the appropriate patient, the correct diagnosis, by an experienced surgeon and duration of symptoms before surgery. We propose screening and training people especially women on the symptoms of CTS. Furthermore, timely performances of surgical operations are necessary.

Acknowledgements

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