Endoscopic and Open Release Similarly Safe for the Treatment of Carpal Tunnel Syndrome. A Systematic Review and Meta-Analysis

Abstract

Background: The Endoscopic Release of Carpal Tunnel Syndrome (ECTR) is a minimal invasive approach for the treatment of Carpal Tunnel Syndrome. There is scepticism regarding the safety of this technique, based on the assumption that this is a rather "blind" procedure and on the high number of severe complications that have been reported in the literature.

Purpose: To evaluate whether there is evidence supporting a higher risk after ECTR in comparison to the conventional open release.

Methods: We searched MEDLINE (January 1966 to November 2013), EMBASE (January 1980 to November 2013), the Cochrane Neuromuscular Disease Group Specialized Register (November 2013) and CENTRAL (2013, issue 11 in The Cochrane Library). We hand-searched reference lists of included studies. We included all randomized or quasi-randomized controlled trials (e.g. study using alternation, date of birth, or case record number) that compare any ECTR with any OCTR technique. Safety was assessed by the incidence of major, minor and total number of complications, recurrences, and re-operations.The total time needed before return to work or to return to daily activities was also assessed. We synthesized data using a random-effects meta-analysis in STATA. We conducted a sensitivity analysis for rare events using binomial likelihood. We judged the conclusiveness of meta-analysis calculating the conditional power of meta-analysis.

Conclusions: ECTR is associated with less time off work or with daily activities. The assessment of major complications, reoperations and recurrence of symptoms does not favor either of the interventions. There is an uncertain advantage of ECTR with respect to total minor complications (more transient paresthesia but fewer skin-related complications). Future studies are unlikely to alter these findings because of the rarity of the outcome. The effect of a learning curve might be responsible for reduced recurrences and reoperations with ECTR in studies that are more recent, although formal statistical analysis failed to provide evidence for such an association.

Level of evidence: I.

Fig 1. Study flow diagram.

Fig 2. Cumulative odds ratios (OR) and 95% confidence interval (CI) for recurrence (panel a) and reoperations (panel b).

The extended lines outside the diamond in the final meta-analytic summary shows the 95% prediction intervals. Asterisk indicates that the study has used a two-portal ECTR.

Fig 3. Cumulative odds ratios (OR) and 95% confidence interval (CI) for minor (panel a) and major (panel b) complications.

The extended lines outside the diamond in the final meta-analytic summary shows the 95% prediction intervals. Asterisk indicates that the study has used a two-portal ECTR.

Fig 4. Cumulative mean difference (MD) and 95% confidence interval (CI) for complications time to return to work or daily activities.

The extended lines outside the diamond in the final meta-analytic summary shows the 95% prediction intervals. Asterisk indicates that the study has used a two-portal ECTR.