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Journal of Hand Surgery Global Online Jan 2024This study aimed to evaluate the safety and effectiveness of mini-open carpal tunnel release (mOCTR) using best-evidence synthesis methods.
PURPOSE
This study aimed to evaluate the safety and effectiveness of mini-open carpal tunnel release (mOCTR) using best-evidence synthesis methods.
METHODS
We systematically searched for prospective studies published from January 2013 to July 2023 that reported outcomes from a minimum of 50 mOCTR cases. The outcomes included Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS), pain visual analog scale (VAS), complication rate, and reoperation rate. Data analysis was performed using a random-effects meta-analysis, with metaregression to identify the associations between patient- and study-level factors with surgical outcomes.
RESULTS
The meta-analysis included 23 studies with 2,303 patients followed for median durations ranging from 6 to 12 months depending on the outcome. Mini-open carpal tunnel release resulted in statistically significant and clinically important improvements in Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (mean difference = -25.5; 95% confidence interval [CI]: -36.4 to -14.5; < .001), BCTQ-SSS (mean difference = -2.2; 95% CI: -2.5 to -1.9; < .001), BCTQ-FSS (mean difference = -2.1; 95% CI: -2.4 to -1.7; < .001), and pain VAS (mean difference = -5.1; 95% CI: -6.2 to -4.1; < .001). The sole predictor of improvement in BCTQ-SSS, BCTQ-FSS, and pain VAS was a higher preoperative score for the respective variable (all < .001). The risk of complications (mainly short-term pillar pain or scar complications) was 8.9% (95% CI: 4.0%-13.8%) and increased with longer incision lengths ( = .008). Revision carpal tunnel release was performed in 0.6% (95% CI: 0.1%-1.0%) of the cases during follow-up. No cases of median nerve transection were reported.
CONCLUSIONS
Based on a best-evidence meta-analysis of contemporary studies, mOCTR significantly improved function and pain, with a relatively low risk of mainly temporary complications. Patient outcomes after mOCTR were influenced by patient symptomatology and surgical incision length.
CLINICAL RELEVANCE
Mini-open carpal tunnel release is an effective surgical option that significantly improves symptoms and function, especially for patients with more severe baseline dysfunction. Surgeons should use the shortest incision that allows adequate visualization to safely divide the transverse carpal ligament.
PubMed: 38313621
DOI: 10.1016/j.jhsg.2023.08.005 -
Hand (New York, N.Y.) Jan 2024Carpal tunnel syndrome (CTS) is a debilitating condition that can cause significant morbidity. Corticosteroid injection (CI) is a popular treatment for CTS. Short-term... (Review)
Review
Carpal tunnel syndrome (CTS) is a debilitating condition that can cause significant morbidity. Corticosteroid injection (CI) is a popular treatment for CTS. Short-term benefits of CI for CTS have been reported, but there is little evidence on long-term outcomes. We performed a systematic review in the PubMed/MEDLINE and Cochrane Library databases to identify studies which reported outcomes of CI for CTS with at least 1-year follow-up. We identified 20 total studies and extracted data on outcomes such as number of patients needing eventual surgery or reinjection, complications, and functional scores. In included studies, 41.6% of patients underwent eventual carpal tunnel release surgery (CTRS), 29% underwent reinjection, there were no major and approximately 34/1133 (3.0%) minor complications, and median/mean time from CI to eventual CTRS ranged from 128 to 446 days. There was disparity on the long-term efficacy of CI for functional outcomes. The evidence indicates that CI is a very low risk procedure that has potential to improve symptoms enough to either prevent or, in most cases, delay the need for further reintervention. However, our conclusions are limited by the heterogeneity of available studies. There is a need for further, high-quality research on this topic.
PubMed: 38240269
DOI: 10.1177/15589447231222320 -
Surgical Technology International Dec 2023To systematically evaluate cases of local anaesthetic systemic toxicity (LAST) in adult urological patients.
OBJECTIVE
To systematically evaluate cases of local anaesthetic systemic toxicity (LAST) in adult urological patients.
METHODS
A search of the Cochrane, Embase, and Medline databases as well as grey literature from 1 January 1974 to 1 February 2023 was performed using reported methods. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible studies were published in English, described LAST secondary to local anaesthetic administration by urological medical staff to an adult patient, and reported >1 symptom of LAST.
RESULTS
One hundred fifty-seven publications were screened, and six eligible studies (all case reports) were identified, representing six cases of LAST in adult urological patients. Patients were aged 29-54 years and one was female. Cases occurred secondary to penile dorsal nerve block (two cases), scrotal self-injection (two), circumcision (one) or trans-vaginal tape insertion (one). Causative drugs were lidocaine (three patients; median dose 600mg) and bupivacaine (three; 200mg). While one patient was found deceased at home and received no treatment, five experienced LAST as inpatients and were discharged with no deficit. Three patients (50%) experienced a state of reduced consciousness or seizures, one experienced psychosis and one had asymptomatic tachyarrhythmia. Management consisted of supportive management (five patients), intravenous lipid emulsion (three) or intravenous thiopental and diazepam (one). Recommended tools suggested that two of these studies were at moderate or high risk of bias.
CONCLUSION
LAST is seen only rarely in adult urology. Most iatrogenic cases occur due to penile dorsal nerve block and most patients have no long-term sequelae. Urologists should be familiar with its presentation and management, and minimise risk by adhering to local anaesthetic maximum safe dose ranges.
PubMed: 38237111
DOI: 10.52198/23.STI.43.UR1725 -
The Cochrane Database of Systematic... Jan 2024Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve at the wrist. Surgery is considered when symptoms persist despite the use of non-surgical...
BACKGROUND
Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve at the wrist. Surgery is considered when symptoms persist despite the use of non-surgical treatments. It is unclear whether surgery produces a better outcome than non-surgical therapy. This is an update of a Cochrane review published in 2008.
OBJECTIVES
To assess the evidence regarding the benefits and harms of carpal tunnel release compared with non-surgical treatment in the short (< 3 months) and long (> 3 months) term.
SEARCH METHODS
In this update, we included studies from the previous version of this review and searched the Cochrane Neuromuscular Specialised Register, CENTRAL, Embase, MEDLINE, ClinicalTrials.gov and WHO ICTRP until 18 November 2022. We also checked the reference lists of included studies and relevant systematic reviews for studies.
SELECTION CRITERIA
We included randomised controlled trials comparing any surgical technique with any non-surgical therapies for CTS.
DATA COLLECTION AND ANALYSIS
We used the standard methodological procedures expected by Cochrane.
MAIN RESULTS
The 14 included studies randomised 1231 participants (1293 wrists). Eighty-four per cent of participants were women. The mean age ranged from 32 to 53 years, and the mean duration of symptoms from 31 weeks to 3.5 years. Trial sizes varied from 22 to 176 participants. The studies compared surgery with: splinting, corticosteroid injection, splinting and corticosteroid injection, platelet-rich plasma injection, manual therapy, multimodal non-operative treatment, unspecified medical treatment and hand support, and surgery and corticosteroid injection with corticosteroid injection alone. Since surgery is generally used for its long-term effects, this abstract presents only long-term results for surgery versus splinting and surgery versus corticosteroid injection. 1) Surgery compared to splinting in the long term (> 3 months) Surgery probably results in a higher rate of clinical improvement (risk ratio (RR) 2.10, 95% confidence interval (CI) 1.04 to 4.24; 3 studies, 210 participants; moderate-certainty evidence). Surgery probably does not provide clinically important benefit in symptoms or hand function compared with splinting (moderate-certainty evidence). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (scale 1 to 5; higher is worse; minimal clinically important difference (MCID) = 1) was 1.54 with splint and 0.26 points better with surgery (95% CI 0.52 better to 0.01 worse; 2 studies, 195 participants). The mean BCTQ Functional Status Scale (scale 1 to 5; higher is worse; MCID 0.7) was 1.75 with splint and 0.36 points better with surgery (95% CI 0.62 better to 0.09 better; 2 studies, 195 participants). None of the studies reported pain. Surgery may not provide better health-related quality of life compared with splinting (low-certainty evidence). The mean EQ-5D index (scale 0 to 1; higher is better; MCID 0.074) was 0.81 with splinting and 0.04 points better with surgery (95% CI 0.0 to 0.08 better; 1 study, 167 participants). We are uncertain about the risk of adverse effects (very low-certainty evidence). Adverse effects were reported amongst 60 of 98 participants (61%) in the surgery group and 46 of 112 participants (41%) in the splinting group (RR 2.11, 95% CI 0.37 to 12.12; 2 studies, 210 participants). Surgery probably reduces the risk of further surgery; 41 of 93 participants (44%) were referred to surgery in the splinting group and 0 of 83 participants (0%) repeated surgery in the surgery group (RR 0.03, 95% CI 0.00 to 0.21; 2 studies, 176 participants). This corresponds to a number needed to treat for an additional beneficial outcome (NNTB) of 2 (95% CI 1 to 9). 2) Surgery compared to corticosteroid injection in the long term (> 3 months) We are uncertain if clinical improvement or symptom relief differs between surgery and corticosteroid injection (very low-certainty evidence). The RR for clinical improvement was 1.23 (95% CI 0.73 to 2.06; 3 studies, 187 participants). For symptoms, the standardised mean difference (SMD) was -0.60 (95% CI -1.88 to 0.69; 2 studies, 118 participants). This translates to 0.4 points better (95% CI from 1.3 better to 0.5 worse) on the BCTQ Symptom Severity Scale. Hand function or pain probably do not differ between surgery and corticosteroid injection (moderate-certainty evidence). For function, the SMD was -0.12 (95% CI -0.80 to 0.56; 2 studies, 191 participants) translating to 0.10 points better (95% CI 0.66 better to 0.46 worse) on the BCTQ Functional Status Scale with surgery. Pain (0 to 100 scale) was 8 points with corticosteroid injection and 6 points better (95% CI 10.45 better to 1.55 better; 1 study, 123 participants) with surgery. We found no data to estimate the difference in health-related quality of life (very low-certainty evidence). We are uncertain about the risk of adverse effects and further surgery (very low-certainty evidence). Adverse effects were reported amongst 3 of 45 participants (7%) in the surgery group and 2 of 45 participants (4%) in the corticosteroid injection group (RR 1.49, 95% CI 0.25 to 8.70; 2 studies, 90 participants). In one study, 12 of 83 participants (15%) needed surgery in the corticosteroid group, and 7 of 80 participants (9%) needed repeated surgery in the surgery group (RR 0.61, 95% CI 0.25 to 1.46; 1 study, 163 participants).
AUTHORS' CONCLUSIONS
Currently, the efficacy of surgery in people with CTS is unclear. It is also unclear if the results can be applied to people who are not satisfied after trying various non-surgical options. Future studies should preferably blind participants from treatment allocation and randomise people who are dissatisfied after being treated non-surgically. The decision for a patient to opt for surgery should balance the small benefits and potential risks of surgery. Patients with severe symptoms, a high preference for clinical improvement and reluctance to adhere to non-surgical options, and who do not consider potential surgical risks and morbidity a burden, may choose surgery. On the other hand, those who have tolerable symptoms, who have not tried non-surgical options and who want to avoid surgery-related morbidity can start with non-surgical options and have surgery only if necessary. We are uncertain if the risk of adverse effects differs between surgery and non-surgical treatments. The severity of adverse effects may also be different.
Topics: Female; Humans; Male; Adrenal Cortex Hormones; Carpal Tunnel Syndrome; Drug-Related Side Effects and Adverse Reactions; Occupational Therapy; Pain; Quality of Life; Adult; Middle Aged
PubMed: 38189479
DOI: 10.1002/14651858.CD001552.pub3 -
Frontiers in Psychiatry 2023Posttraumatic stress disorder (PTSD) is a chronic disorder resulting from exposure to traumatic events. In recent years, sympathetic nerve blocks have gained interest as...
Posttraumatic stress disorder (PTSD) is a chronic disorder resulting from exposure to traumatic events. In recent years, sympathetic nerve blocks have gained interest as an emerging treatment modality for PTSD. They have been shown to reduce autonomic dysfunction associated with PTSD symptoms, particularly in refractory and treatment-resistant patients. However, there is limited evidence regarding the technique's effectiveness in PTSD patients. Therefore, this scoping review was designed to update and summarize the current literature on this topic to inform the design of future clinical trials and studies. Our review of 22 studies (mostly case reports and series) included 1,293 PTSD patients who received sympathetic nerve blocks, primarily military service members and veterans, with a median age of 42.2 years. 0.5% Ropivacaine was the preferred anesthetic, and the right sided stellate ganglion block was the most commonly used technique. Relapse of symptoms was reported commonly, resulting in additional nerve block sessions. Most reported side effects were mild and transient. Despite the encouraging results, we remain cautious in interpreting the benefit of the technique due to the lack of sufficient standardized clinical trial data, heterogeneity in reported results, and the potential for bias in reporting. Future studies should focus on evaluating and addressing the technique's effectiveness, safety, tolerability, and indications.
PubMed: 38188052
DOI: 10.3389/fpsyt.2023.1309986 -
BMC Neurology Dec 2023Neuromuscular diseases (NMD) emerged as one of the main side effects of the COVID-19 vaccination. We pooled and summarized the evidence on the clinical features and...
BACKGROUND
Neuromuscular diseases (NMD) emerged as one of the main side effects of the COVID-19 vaccination. We pooled and summarized the evidence on the clinical features and outcomes of NMD associated with COVID-19 vaccination.
METHODS
We comprehensively searched three databases, Medline, Embase, and Scopus, using the key terms covering "Neuromuscular disease" AND "COVID-19 vaccine", and pooled the individual patient data extracted from the included studies.
RESULTS
A total of 258 NMD cases following COVID-19 have been reported globally, of which 171 cases were Guillain-Barré syndrome (GBS), 40 Parsonage-Turner syndrome (PTS), 22 Myasthenia Gravis (MG), 19 facial nerve palsy (FNP), 5 single fiber neuropathy, and 1 Tolosa-Hunt syndrome. All (100%) SFN patients and 58% of FNP patients were female; in the remaining NMDs, patients were predominantly male, including MG (82%), GBS (63%), and PTS (62.5%). The median time from vaccine to symptom was less than 2 weeks in all groups. Symptoms mainly appeared following the first dose of vector vaccine, but there was no specific pattern for mRNA-based.
CONCLUSION
COVID-19 vaccines might induce some NMDs, mainly in adults. The age distribution and gender characteristics of affected patients may differ based on the NMD type. About two-thirds of the cases probably occur less than 2 weeks after vaccination.
Topics: Adult; Humans; Female; Male; COVID-19 Vaccines; COVID-19; Neuromuscular Diseases; Myasthenia Gravis; Guillain-Barre Syndrome; Bell Palsy; Facial Paralysis
PubMed: 38082244
DOI: 10.1186/s12883-023-03486-y -
Brain, Behavior, and Immunity Feb 2024Vagus nerve stimulation (VNS) has been identified as an innovative immunosuppressive treatment strategy in rodent studies. However, its' clinical potential is still... (Meta-Analysis)
Meta-Analysis
Vagus nerve stimulation (VNS) has been identified as an innovative immunosuppressive treatment strategy in rodent studies. However, its' clinical potential is still unclear. Therefore, we aimed to assess whether VNS can reduce inflammatory proteins and/or immune cells in humans, through a pre-registered systematic review and meta-analysis according to PRISMA guidelines. The databases Cochrane, Pubmed and World of Knowledge were searched in duplicate up to the 3rd of March 2022 and publications from identified clinical trial registrations were identified until 20th of August 2023. Studies were included if they provided peer-reviewed data for humans who received VNS as short-term (<=1 day) or long-term (>=2 days-365 days) stimulation and reported at least one cytokine or immune cell after treatment.Screening of title, abstract, full text, and data extraction was performed in duplicate by two independent reviewers. Data were pooled using a random-effects model and meta-regression was performed for moderating factors. Reporting bias was assessed. The standardized mean difference (Hedge's g) was used to indicate overall differences of cytokine data (mean and standard deviation or median and interquartile range at the study level) to test our a-priori hypothesis. The systematic review of 36 studies with 1135 participants (355 receiving a control/sham condition and 780 receiving VNS) revealed anti-inflammatory effects of VNS for cytokines in several reports, albeit often in subgroup analyses, but our meta-analyses of 26 studies did not confirm these findings. Although most cytokines were numerically reduced, the reduction did not reach statistical significance after VNS: not in the between-group comparisons (short-term: TNF-α: g = -0.21, p = 0.359; IL-6: g = -0.94, p = 0.112; long-term: TNF-α: g = -0.13, p = 0.196; IL-6: g = -0.67, p = 0.306); nor in the within-study designs (short-term: TNF-α: g = -0.45, p = 0.630; IL-6: g = 0.28, p = 0.840; TNF-α: g = -0.53, p = 0.297; IL-6:g = -0.02, p = 0.954). Only the subgroup analysis of 4 long-term studies with acute inflammation was significant: VNS decreased CRP significantly more than sham stimulation. Additional subgroup analyses including stimulation duration, stimulation method (invasive/non-invasive), immune stimulation, and study quality did not alter results. However, heterogeneity was high, and most studies had poor to fair quality. Given the low number of studies for each disease, a disease-specific analysis was not possible. In conclusion, while numeric effects were reported in individual studies, the current evidence does not substantiate the claim that VNS impacts inflammatory cytokines in humans. However, it may be beneficial during acute inflammatory events. To assess its full potential, high-quality studies and technological advances are required.
Topics: Humans; Vagus Nerve Stimulation; Tumor Necrosis Factor-alpha; Interleukin-6; Cytokines; Anti-Inflammatory Agents; Vagus Nerve
PubMed: 38070618
DOI: 10.1016/j.bbi.2023.12.008 -
Journal of Clinical Medicine Nov 2023Carpal tunnel syndrome (CTS) is the most common entrapment syndrome, primarily affecting women between the ages of 40 and 70, and conservative treatments are the first... (Review)
Review
BACKGROUND
Carpal tunnel syndrome (CTS) is the most common entrapment syndrome, primarily affecting women between the ages of 40 and 70, and conservative treatments are the first option for mild-to-moderate CTS. However, the comparisons between extracorporeal shock wave therapy (ESWT) and other non-surgical methods in the treatment of mild-to-moderate CTS remain controversial, and an updated systematic review is needed.
METHODS
An electronic search was performed, and all available articles until August 2023 were included in the analysis. The overall quality of evidence was assessed by the GRADE approach. Meta-analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) with 95% confidence intervals (CIs).
RESULTS
A total of 19 RCTs were included. Low-level quality evidence showed that ESWT outperformed the control intervention in terms of functional improvements, pain relief, electrodiagnostic parameters, and cross-sectional area of the median nerve at any time point of follow-up. Compared to local corticosteroid injection (LCI), there were statistically better improvements in functional improvements, pain relief, and electrodiagnostic parameters at 3 and 6 months of follow-up.
CONCLUSIONS
There is low-level quality evidence to show that both fESWT and rESWT are more clinically effective than controls in symptom relief, functional enhancement, and electrophysiologic parameters' improvement for patients with mild-to-moderate CTS at any time point of follow-up. Compared with LCI, ESWT yielded similar short-term (<1 month) but better medium- (1-6 months) and long-term (>6 months) improvements in pain relief and functional recovery with fewer potential complications.
PubMed: 38068415
DOI: 10.3390/jcm12237363 -
BMC Musculoskeletal Disorders Dec 2023A chronic Achilles tendon rupture (ATR) is defined as an ATR that has been left untreated for more than four weeks following rupture. This systematic review aims to...
INTRODUCTION
A chronic Achilles tendon rupture (ATR) is defined as an ATR that has been left untreated for more than four weeks following rupture. This systematic review aims to summarize the outcomes of chronic ATR treated using either a gastrocnemius aponeurosis flap or semitendinosus tendon graft.
METHODS
A systematic search was conducted in three databases (PubMed, Scopus and Cochrane), for studies describing outcomes after surgical treatment of chronic ATR using gastrocnemius aponeurosis flaps or semitendinosus tendon grafts with more than 10 patients included. The studies were assessed for quality and risk of bias using the Methodological Items used to assess risk of bias in Non-Randomized Studies (MINORS).
RESULTS
Out of the 818 studies identified with the initial search, a total of 36 studies with 763 individual patients were included in this systematic review. Gastrocnemius aponeurosis flap was used in 21 and semitendinosus tendon graft was used in 13 of the studies. The mean (SD) postoperative Achilles tendon Total Rupture Score (ATRS) for patients treated with a gastrocnemius aponeurosis flap was 83 (14) points and the mean (SD) American Orthopaedic Foot and Ankle Score (AOFAS) was 96 (1.7) points compared with ATRS 88 (6.9) points and AOFAS 92 (5.6) points for patients treated with a semitendinosus tendon graft. The included studies generally had low-quality according to MINORS, with a median of 8 (range 2-13) for all studies.
CONCLUSION
Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts give acceptable results with minimal complications and are valid methods for treating chronic ATR. The main difference is more wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries in patients treated with a semitendinosus grafts. The current literature on the subject is of mainly low quality and the absence of a patient-related outcome measure validated for chronic ATR makes comparisons between studies difficult.
LEVEL OF EVIDENCE
Level IV.
Topics: Humans; Achilles Tendon; Aponeurosis; Hamstring Tendons; Surgical Flaps; Muscle, Skeletal; Tendon Injuries; Rupture; Treatment Outcome
PubMed: 38066531
DOI: 10.1186/s12891-023-07064-8 -
Clinical Anatomy (New York, N.Y.) May 2024Three commonly used approaches to the forearm in orthopedic surgery are Henry's, Thompson's, and the ulnar approach, each of which has the potential to cause injury to... (Review)
Review
Three commonly used approaches to the forearm in orthopedic surgery are Henry's, Thompson's, and the ulnar approach, each of which has the potential to cause injury to nerves around the wrist. Preserving these nerves is important to prevent complications such as neuroma formation and motor and sensory changes to the hand. We conducted a review of the literature to assess the nerves at risk and whether 'safe zones' exist to avoid these nerves. An independent reviewer conducted searches in Embase and MEDLINE of the literature from 2010 to 2020. A total of 68 papers were identified, with 18 articles being included in the review. Multiple nerves were identified as being at risk for each of the approaches described. In the anterior approach, the palmar cutaneous branch of the median nerve (PCBMN) is most at risk of injury. An incision immediately radial to the flexor carpi radialis (FCR) or directly over the FCR is most likely to avoid injury to both superficial branch of the radial nerve (SBRN) and PCBMN. With Thompson's approach, the safest zone for an incision is directly over or slightly radial to Lister's tubercle to avoid injury to SBRN and lateral cutaneous nerve of the forearm. For the ulnar approach, a safe zone was shown to be on the ulnar side of the wrist around the ulnar styloid (US) when the forearm was in supination or a neutral position to avoid injury to the dorsal branch of the ulna nerve (DBUN). Care must be taken around the US due to the density of nerves and the proximity of the last motor branch of the posterior interosseous nerve to the ulnar head. This review highlighted the proximity of nerves to the three most common surgical incisions used to access the forearm. In addition, anatomical variations may exist, and each of the nerves identified as being at risk has multiple branches. Both factors increase the potential of intraoperative damage if the anatomy is not properly understood. The surgeon must adhere carefully to the established approaches to the wrist and distal forearm to minimize damage to nerves and optimize surgical outcomes for the patient.
Topics: Humans; Forearm; Wrist; Wrist Joint; Ulna; Peripheral Nerves; Cadaver
PubMed: 38059329
DOI: 10.1002/ca.24129