Table of contents

Editorial
Meet the team
Dr Alan Walker
Original Contribution/Clinical Investigation
The discriminative value of two functional assessment scales compared for predicting falls in institutionalized elderly people in Iran
The relationship between depression and educational levels, the retirement years and chronic diseases of elderly men in area 6 of Tehran's municipality 2005
Evaluating Infectious Etiologies of Hospitalization in Elderly Population of Iran
Models and Systems of Elderly Care
The Economic Impact of Treating Geriatric Hip Fracture - A Study at Rustaq Referral Hospital , South Batinah Region, Oman
Clinical Research and Methods
Acceptable Satisfaction after Carpal Tunnel Decompression in Elderly Patients

 

Acceptable Satisfaction after Carpal Tunnel Decompression in Elderly Patients

Authors
Hamid Namazi
Assistant Professor of Shiraz University of Medical Sciences
Department of Orthopaedic Surgery
Zahra Majd
General Physician

Correspondence:
Hamid Namazi
Tel: +98 711 6246093
FAX: +98 711 6231410
PO.BOX: 71324
E-mail: Namazih@sums.ac.ir


Abstract:

Background: A number of factors have been reported to influence the outcome of carpal tunnel decompression including gender, alcohol use, mental health status, and presence of objective neurologic signs. Moreover, there was an attempt to determine the outcomes of carpal tunnel decompression in elderly patients and whether outcomes can be predicted by the severity of pre-surgical nerve conduction study results.

Methods: In this retrospective study 57 patients (83 hands) over 60 years of age who had carpal tunnel decompression between 1998-2002 inclusive. All patients responded to a universal questionnaire. In all patients preoperative nerve conduction studies were scored by the grading system from 1 to 6.

Results: Seventy percent had marked to severe neurophysiologic changes (grade 4-6). The mean post-surgical symptom severity score was 1.47. There was a significant relationship between pre-surgical nerve conduction grade and post-surgical symptom severity score.

Conclusion: Elderly patients have low post-surgical symptom scores and have good satisfaction levels after decompression.

Keywords: carpal tunnel; satisfaction; decompression

Introduction

There are lots of controversies about the effectiveness of carpal tunnel release in elderly patients. Moreover, some have reported satisfactory outcomes following surgery in the elderly (Papaloizos and Simonetta, 1991; Tomaino and Weiser; 2001; Weber and Rude, 2005) (1,2,3), while others have reported worse outcomes in older patients (Atroshi et al, 1998; Greenslade et al, 2004; Porter et al, 2002) (4, 5, 6).

Pre-surgical nerve conduction studies are used to aid the diagnosis of carpal tunnel syndrome (CTS). The predictive value of nerve conduction studies, however, remains controversial (7, 8, 9). There was an attempt to re-evaluate the impact of age and neurophysiological studies upon outcome of carpal tunnel decompression.

Materials and methods

Between 1998 and 2002, 83 elective carpal tunnel decompressions in 57 patients over 65 years of age were performed in our center. Inclusion criteria were as follows: Patient over 65 years of age at time of surgery, a minimum of 1.5 years of follow-up evaluation, neurophysiologically proven median nerve compression, and the patient's ability to complete a standardized questionnaire. There were 26 bilateral procedures. Mean age was 68.5 years (range 65-78) and 50 (87%) of the patients were women.

In our center routinely neurophysiological study is requested for all of the patients who have problems in favor of CTS. All nerve conduction studies were graded based on amplitude- weighted system (Table 1).

Table 1: Grading Carpal Tunnel Syndrome by Using Neurophysiologic Criteria

Grade Palmar Latency Sensory Conduction Velocity Distal Motor Latency Sensory Amplitude Motor Amplitude
6(Severe) ----     ---- ---- absent absent
5(Very marked) ---- ---- ---- >7.0 SD or absent and>4.0 SD
4(Marked) ---- >5.0SD or >5.0 SD and>4.5 to <7.0SD or absent or>4.0SD
3(Moderate) ---- >4.0 to <5.0 SD or >4.0 to <5.0 SD and <4.5 SD or <4.0SD
2(Mild) >3.5 SD or >3.0 to <4.0SD or >3.0 to <4.0SD and <3.0SD and <3.0SD
1(Borderline) 2.5 -3.5SD and <3.0SD and <3.0SD and <3.0SD and <3.0SD
0(Normal) all <2.5 SD And<2.5 SD and<2.5 SD and<2.5 SD and<2.5 SD

All of the patients were operated under general anesthesia or bier block anesthesia in the operating room after tourniquet inflation. The incision is marked about 6 millimeter ulnar to the thenar crease to ensure that any scarring is away from the median nerve and that the incision is well ulnar to the palmar cutaneous branch of median nerve, which is located in the thenar crease. A curvilinear incision is made paralleling the thenar crease, 2-3 centimeter in length, and ending just distal to the transverse wrist crease. The transverse carpal ligament was divided under direct vision. No patient underwent endoscopic decompression. The mean follow-up for each patient was 26 months (range, 14-39 months).

All patients responded to symptom severity questionnaire of Levine et al. This questionnaire has eleven questions. Each question is scored from 1 to 5, where 1 is normal or no symptoms and 5 is the worst score. A mean score is calculated for each patient. Statistical analysis was performed using statistical software.

Results

Seventy percent had marked to severe pre-surgical nerve conduction studies grades. The mean post surgical severity score for all patients was 1.47. In 58 hands (69%) had none to mild symptoms and the others (25 hands, 31%) had mild to moderate symptoms. No patient had symptom in favor of severe grades. All patients with post surgical symptoms severity score greater than 2 had a pre-surgical neurophysiological study results of grade 4 or greater. For better evaluation of outcome of surgery, the questions were categorized into three groups: 5 questions (1-5) were concerned with pain, 4 questions (6, 8-10) with numbness and tingling, and 2 questions (7, 11) with function and strength. The mean score for the pain score, the numbness score, and the functional score were 1.58, 1.44 and 1.39. This showed little difference in outcomes with regard to pain or sensory symptoms or function. There was a significant relationship between nerve conduction grade and symptom severity score (P.value <0.01). Despite this relationship, full range of scores from 1.1 to 2.9 were seen in the most severe grade and most patients with grade 5, 6 were satisfied with the outcome of their surgery.


Discussion

There is controversy over the outcome of carpal tunnel decompression in elderly patients. Two small retrospective studies have reported satisfactory outcomes form surgery in elderly patients.

Papaloizos and Simonetta in 1991 studied 37 patients aged above 75 years and reported that paresthaesia and loss of cutaneous sensitivity were improved in 76% and 61% of cases, respectively, and that only three patients (8%) reported no improvement in their symptoms following surgery (1). Tomaino and Weiser in 2001 reported that 11 of thirteen patients over 70 years of age with advanced carpal tunnel syndrome were satisfied with the outcome of surgery and that, of all patients with preoperative numbness, the symptoms had resolved in nine patients at 2 year follow-up (2). Weber and Rude have recently reported a prospective series of 75 patients over 65 years of age in which, at 6 month follow-up, 83% of patients were completely, or very, satisfied with their surgery and only two patients were dissatisfied. (3)

Some comparative studies have reported worse outcomes in older patients. Porter showed that patients over 60 years of age had significantly less improvement in symptom severity and functional status and only 66% were satisfied after surgery compared with 87% satisfaction in patients under 60 years of age (6). Bland found that older patients had a poorer prognosis independent of other factors. (7)

But, in the present study, the mean severity score was 1.47 which compares favorably with the published mean score of 1.3 to 1.9 from other studies using this instrument (6, 8, 9, 10). Results of this study confirm those of Tomaino and Weiser and Papaloizos and Simonetta studies.

In most centers neurophysiologic studies play an important role in the diagnosis and management of CTS. Various grading scales have been proposed that are based largely on conduction velocity criteria. Although in the present study there was a significant relationship between the presurgical conduction velocity and postsurgical total severity score.

Several authors have found that nerve conduction studies do not improve or predict the clinical outcome of carpal tunnel surgery (11, 12, 13, 14). In light of these findings many recent studies have questioned the need for nerve conduction studies (15, 16). In summary this study revealed high satisfaction rates and good outcomes can be expected in CTS surgery in the elderly even when neurophysiologic tests show marked abnormalities. The post surgical symptom severity scores in our group compare favorably with published scores in younger patients. Severe pre-surgical neurophysiologic abnormalities should not preclude elderly patients from surgery because they tend to have higher symptom severity scores before surgery than the milder grades; they are still likely to be satisfied with surgery, particularly if realistic expectations about surgical outcome are established at the outset.

References
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