Predictive Factors Associated with the Need for Simultaneous Carpal Tunnel and Ulnar Nerve at the Elbow Releases

Abstract

Introduction: Carpal tunnel syndrome and ulnar nerve compression at the elbow (e.g., cubital tunnel syndrome) are the most common upper extremity compressive neuropa- thies treated by hand surgeons. The aim of this study was to determine demographic factors and comorbidities that can help predict those patients most likely to undergo concurrent release of both the carpal tunnel and ulnar nerve at the elbow. We hypothesized that certain comorbidities, such as diabetes, would be associated with an increased risk for the necessity of concomitant procedures.

Methods: Using Truven Marketscan® database, all patients who underwent carpal tunnel release were identified from 2010 to 2017 using Current Procedural Terminology (CPT) codes. Patients were only included if they had continuous enrollment in the database for 12 months preoperatively. Preoperative comorbidities and concurrent procedures were collected us- ing CPT and ICD-9 and 10 codes. Patients who underwent simultaneous carpal tunnel and ulnar nerve at the elbow release on the same day were compared to those patients who underwent carpal tunnel release alone. Additionally, patients who underwent either procedure initially and then went on to have the other procedure at a later date were compared. Univariate analysis and binomial logistic regression were performed to assess the contribution of patient demographics and comorbidities on the necessity of simultaneous release.

Results: 259,574 patients underwent carpal tunnel release surgery and were included in the study. 24,401 (7.9%) of pa- tients also underwent simultaneous ulnar nerve release at the elbow on the same day. Significant risk factors associated with the need for simultaneous release, were male gender [(Odds Ratio (OR): 2.05, Confidence Interval (CI): 2.00-2.11, p < 0.001)], chronic pain (OR: 1.78, CI: 1.68-1.87, p < 0.001), diabetes (OR: 1.29, CI: 1.25-1.33, p < 0.001), history of al- coholism (OR: 1.23, CI: 1.10-1.38, p < 0.001), chronic renal disease (OR: 1.26, CI: 1.18-1.34, p < 0.001), tobacco use (OR: 1.49, CI: 1.42-1.56, p < 0.001), and patients with congestive heart failure (OR: 1.26, CI: 1.17-1.35, p < 0.001). Patients with consumer driven health plans and high deductible health plans (HDHP) were 1.5 times more likely to have simultane- ous release compared to those with comprehensive plans (OR: 1.46, CI: 1.37-1.56, p < 0.001; OR: 1.45, CI: 1.34-1.57, p < 0.001; respectively). For necessity of subsequent carpal or ulnar nerve release after either primary procedure, patients with a minimum of 3 years enrollment in the database were analyzed. Of the 113,505 patients who underwent initial carpal tunnel release, 1,746 (1.5%) went on to undergo release of the ulnar nerve at the elbow. Of the 12,673 patients who had initial ulnar nerve releases at the elbow, 721 (5.7%) required additional release of the carpal tunnel.

Conclusion: Identification of patient demographic factors and comorbidities that can help predict the likelihood of si- multaneous release of both the carpal tunnel and ulnar nerve at the elbow can help direct management of these patients. Combining the two procedures can help save resources, minimize patient burden, and help reduce excess health care utilization.