CTS Surgery: What Does the Science Say?
A recent article in the Journal of the American Medical Association “Splinting vs. Surgery in the Treatment of Carpal Tunnel Syndrome” (Gerritsen et al., JAMA. 2002 Sep 11;288(10):1245-51) reported that scientists studied a group of patients with Carpal Tunnel Syndrome (CTS).
Some study subjects received wrist splints to wear at night for at least six weeks. The others received surgery. Carpal tunnel surgery was limited to cutting the transverse carpal ligament to relieve pressure on the median nerve. Other procedures sometimes done in conjunction with carpal tunnel tendon release were not performed.
The Authors conclude that surgery was more effective than splinting in reducing the number of nights patients woke up because of pain, numbness and tingling in the hands. Surgery was also more effective in reducing the severity of these symptoms.
Three months after the beginning of the study, surgery produced complete recovery or much improvement in 80% of those who received it. Splints achieved similar improvements for only 54%. After 18 months, the rates increased to 90% for surgery group and 75% for splints. However by that time, 41% of patients who started in the splint group had surgery.
The researchers concluded that doctors should not wait until non-surgical treatments have failed before recommending surgery to their CTS patients. Dr. Annette Gerritsen, the leader of the research team, told the Associated Press that the findings “suggest that surgery should be the first rather than the last option for most patients”. The UAW has reservations about this interpretation. See the Commentary below.
UAW Commentary
The UAW Health and Safety Department consulted with a number of expert physicians in preparing the following comments. Where you have questions about medical treatment, consult your personal physician.
The study by Gerritsen et al. was widely quoted in the popular press as showing that carpal tunnel surgery should be the first treatment option for carpal tunnel syndrome (CTS) rather than the last. This conclusion is overstated. While the study makes an important contribution to our knowledge about CTS, it does not settle many of the critical questions concerning the clinical management of this serious and disabling occupational illness. The most important observations were that 10% of the surgery cases, and 25% of those receiving splinting were not improved after 18 months. This long term disability emphasizes the need for prevention by reducing ergonomic risk factors before the disease becomes evident.
A limitation of the study was that only splinting was compared to surgery. Non-surgical treatments for CTS not studied include anti-inflammatory medication, ultrasound, joint manipulation, exercise and massage. Activity Modification is a primary method of controlling CTS. This might include time off of work or work restrictions to eliminate exposure to CTS risk factors. Workers may be asked to reduce activities outside of work that may worsen their symptoms. Activity Modification is not addressed in this study.
Other important factors impair interpretation of the study. The article did not discuss whether any of the patients were employed, what their exposures at work may have been, whether they lost time from work and, most importantly, whether the surgery patients and the splint patients missed the same amount of time from work.
It was noted that for subjects who were randomized to surgical therapy “no specific period off work [immediately following the surgery for wound healing] was recommended”. Surgical patients likely had time off work for a few weeks following surgery to allow for wound healing, which is medically appropriate. If the surgery patients spent more time away from occupational exposures than splinting patients, that time could have made an indepen-dent contribution to their healing that the researchers attributed to surgery. What might have been observed if all splint patients had also been required to be off work for a few weeks? The article is silent on whether patients who underwent surgery were given any work restrictions (tempo-rary or permanent) following return to work.
There are no scientific studies of the role of permanent or temporary work restrictions beyond the immediate post-operative recovery period for surgery for CTS, and opinions among surgeons vary widely.
Some surgeons believe that carpal tunnel release surgery, by in cutting the transverse carpal ligament, changes the structure of the hand to such an extent that the disease process is stopped. Some surgeons may believe that after the procedure, workplace exposures have minimal impact on future
