Abstract & Commentary
Synopsis: This study confirms that both nocturnal wrist splints and surgical release are effective options of treatment and suggests that surgical release is more effective in treating carpal tunnel syndrome.
Source: Gerritsen A. JAMA. 2002;228:1245-1251.
This randomized controlled study compared surgery vs nocturnal wrist splints in 176 patients with idiopathic carpal tunnel syndrome. The primary outcome was self-reported improvement in symptoms as assessed with a general improvement scale at 18 months.
Sixty-eight of the 87 patients assigned to receive open tunnel release and 79 of 87 patients assigned to 6 weeks of nocturnal wrist splints returned for follow-up at 18 months. Ninety percent of the patients assigned to receive surgery reported improvement in the pain scale; 75% of the nocturnal splint group reported improvement (mean difference, 15%; 95% CI, 3-27%; P = 0.02). Fifty-three percent of the surgical and 46% of the splint group reported adverse effects. In comparing the 2 therapies, 7 patients would have had to be treated with surgery instead of splints to see 1 clinical improvement (NNT = 7); one additional adverse effect can be expected for every 14 patients who were treated with surgery instead of wrist splints (NNH = 14).
Comment by Jeff Wiese, MD
Carpal tunnel syndrome afflicts between 1-9% of adults. Pain, paresthesias, or weakness results from compression of the median nerve by the overlying fascia. Symptoms are exacerbated by nocturnal wrist flexion during deep sleep and may persist into waking hours. This study confirms that both nocturnal wrist splints and surgical release are effective options of treatment and suggests that surgical release is more effective in treating carpal tunnel syndrome.1,2
The results of this study should be interpreted with caution, however. In this study, 326 patients were initially enrolled, but only 176 patients completed the trial. The 111 patients who did not meet inclusion criteria by way of nerve conduction studies may represent a cohort with less severe disease who may have been adequately treated with the more conservative treatment option of wrist splinting. The study subjects in this trial may represent a population with more severe disease, and therefore, would be more amenable to surgical intervention.
This study also had considerable dropout; 39 subjects were excluded or refused participation, and another 29 subjects withdrew or did not follow up at 18 months. Because the reason for withdrawal or refusal to participate is unknown, the validity of this study may be tarnished.
The American Academy of Neurology (AAN) recommends that all patients first attempt a trial of wrist splints prior to surgical release.3 While this trial demonstrates that surgery is more successful than wrist splinting, there was still considerable success with wrist splinting (75%) and less adverse effects. There also does not appear to be an adverse risk for engaging in a trial of wrist splinting prior to surgical release. However, this trial suggests that many of the patients who first try wrist splinting will ultimately require surgical release (41%).
Dr. Wiese, Chief of Medicine, Charity, and University Hospitals, Associate Chairman of Medicine, Tulane Health Sciences Center, is Associate Editor of Internal Medicine Alert.
References
1. Gerritsen A, et al. J Neurol. 2002;249:272-280.
2. Manente G, et al. Muscle Nerve. 2001;24:1020-1025.
3. American Academy of Neurology. Neurology. 1993;43: 2406-2409.
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This randomized controlled study compared surgery vs nocturnal wrist splints in 176 patients with idiopathic carpal tunnel syndrome.
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