Iain Whitaker

Cronfa at Swansea University

SHORT REPORTS AND CORRESPONDENCECarpal tunnel decompression. The impact oftourniquet, anaesthesia type, and operating teamon patient satisfaction scoresA. Gulatia, I.S. Whitakerb,*, M. Jaggardc, B.N. Archd,J. Hopkinson-WoolleyeaDepartment of Emergency Medicine, Addenbrooke’s Hospital NHS Trust, Cambridge, UKbUniversity of Cambridge, Cambridge, UKcQueen’s Medical Centre, Nottingham, UKdDepartment of Medical Statistics, University of Cambridge, Cambridge, UKeIpswich Hospital, Ipswich, UKReceived 5 May 2004; accepted 10 June 2004Carpal tunnel syndrome is a frequently encounteredcause of upper extremity discomfort and disability,with an annual incidence of 0.1% in the generalpopulation1 and over 2% in high-risk occupations.2 Alarge proportion of patients fail to respond toconservative treatment with wrist splints, analge-sics, lifestyle modification and corticosteroid injec-tion.3 In this group of patients, surgical release ofthe flexor retinaculum is indicated in order todecompress the carpal tunnel, as first described byLearmonth in 1933.4 Surgical decompression of thecarpal tunnel can be performed under local orgeneral anaesthetic and with or without a tourni-quet. A variety of techniques have been described,each with its individual merits and drawbacks. Theincreasing role of clinical governance in modem daypractice places an even greater emphasis on theneed to establish whether specific interventionsmeet patients’ expectations. Previous studies haveevaluated outcome following surgical decompres-sion of the carpal tunnel using physical findings,disease specific questionnaires, and electromyo-graphy, with reported success rates ranging from 70to 90%.5We used a validated patient completed ques-tionnaire6 to assess patient satisfaction followingunilateral and bilateral carpal tunnel decompres-sion in a large sample of patients in a districtgeneral hospital setting. We also investigated theimpact of anaesthesia type, tourniquet usage andoperating team on the clinical outcome. Allpatients in the study group were diagnosed by aconsultant hand surgeon, using a mixture of clinicalhistory, clinical tests and EMG recordings.Patients and methodsTwo hundred and eighty nine consecutive patientswho underwent carpal tunnel release betweenFebruary 2000 and June 2001 were posted the PEM(Patient Evaluation Measure) questionnaire.3 Allpatients were at least 6 months post-operative. Theresponse rate was high with an 86% response rate(249). Two hundred and thirty, one sets of noteswere reviewed and the following operativeThe British Association of Plastic Surgeons (2005) 58, 116–119S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2004.06.023*Corresponding author.E-mail address: iain_whitaker@yahoo.comvariables were noted: operating team (hand teamvs other), operating site (unilateral vs bilateral),anaesthetic type (general vs local) and tourniquetusage (tourniquet present vs absent). The resultswere statistically analysed using the Mann–WhitneyU Test.The questionnaireThe PEM questionnaire was devised in 19957 and hassince been shown to be a reliable, valid andresponsive tool for assessing outcomes of disordersof the hand.6 It uses a simple layout with thequestions asked in a visual analogue form. Patientsare required to circle a number from one to seven todetermine the magnitude of each answer, with alow score signifying a higher level of satisfaction ineach case.ResultsThe sample consisted of 231 patients of which 160(69.3%) were female. The mean age was 57.2 (SD15.7). Most patients were operated on by a handteam (63.6%), were given a local anaesthetic(84.0%), were operated on at the unilateral site(72.7%) and had a tourniquet used (79.2%). Themedian (IQR) PEM score was 26 (17.0,44.5). Thefrequency distribution of the total PEM score wasnegatively skewed with patients tending to havelow scores indicating a high level of satisfaction.Neither age nor gender was associated with totalPEM score.None of the four operative variables tested wereassociated with the total PEM score (Table 1). Thusthere were no significant differences between themedian scores for the different operating team(p ¼ 0:68; Fig. 1), operating site (p ¼ 0:63; Fig. 2),anaesthetic type (p ¼ 0:32; Fig. 3) or tourniquetusage (p ¼ 0:70; Fig. 4). Patients who were notoperated on by the hand team (Fig. 1) or who had alocal anaesthetic (Fig. 3) were noted to be morevariable in their scores.DiscussionThe low median PEM score (26) and negativelyskewed PEM score distribution both correlate with ahigh level of patient satisfaction following carpaltunnel decompression. This observation is consist-ent with the findings of several other studies, whichhave used patient administered questionnaires toassess the results of carpal tunnel releases.5,8,9Figure 2 Boxplot showing distribution of total score byoperation site.Table 1 Median (interquartile range) PEM scores for different operative variables and corresponding p-values (Mann–Whitney UTest)Variable Median PEM Score p-valueHand team/other 27(18,41.5) 26(16,52) 0.68Unilateral/bilateral 26(17,44) 27(20.5,48) 0.63Local/general anaesthetic 27(18,47) 25(16,38) 0.32Tourniquet used/not used 26(18.5,45) 26.5(16.5,42.5) 0.70Figure 1 Boxplot showing distribution of total score byoperation team.Carpal tunnel decompression 117Such questionnaires are more sensitive to theclinical alteration produced by surgical carpaltunnel decompression, as compared with physicalassessment.10 Although the opinions of surgeons areuseful in evaluating post-operative outcome,patient satisfaction remains the standard formeasuring the success of surgery.We found the PEM questionnaire to be anefficient way of collecting information on outcomefor audit purposes. The advantage of such genericassessment is that the impact of disease onpatients’ quality of life is also considered, a factorwhich may be overlooked with disease-specifictools such as the Levine questionnaire for carpaltunnel syndrome.9 The questionnaire’s simpleanalogue scale was well-received by the patientsin this study, reflected by the high response rate(86%) achieved.There is an increasing trend towards sub-special-isation within surgery with the result that patientsbenefit from the increased levels of knowledge andcompetence on offer. However, at the same timethe dangers of over-specialisation have been welldiscussed.11 This study compared the results ofthree different specialist hand teams against all theother orthopaedic operating teams. In our study,specialist hand teams achieve no greater patientsatisfaction. A significant proportion of patients inthis study (27.3%) exhibited bilateral symptoms.Patients sometimes poorly tolerate bilateral carpaltunnel decompression and are occasionally disap-pointed when one hand fails to show the dramati-cally rapid recovery that the other does. However,in this study simultaneous carpal tunnel release atboth wrists produced an equivalent level of patientsatisfaction to those patients who were operated ononly one hand.Several previous studies have addressed themerits and drawbacks of performing carpal tunneldecompression using different anaesthetic tech-niques. Phalen in 196612 first raised the possibilityof carrying out carpal tunnel decompression underlocal anaesthesia. Local anaesthesia is well toler-ated,13 can be performed by surgeons themselves,is suitable for outpatient surgery and is quick andsafe to administer in the small quantitiesrequired.14 The use of a tourniquet for carpaltunnel decompression has been the source ofmuch interest. Tourniquet control creates a blood-less field, which assists anatomic dissection andenables better visualisation of important struc-tures. It may be argued that this is of limited valuedue to the predictable nature and limited dissectioninvolved in carpal tunnel release. Tourniquetapplication may cause subclinical, temporarychanges in the forearm muscles, constrainingavailable operative time and contributing to post-operative hand oedema.15Although much attention has been paid to thesafety and efficacy of carpal tunnel decompressionunder local or general anaesthetic and with orwithout a tourniquet, there is little information onwhether these variables actually affect patientsatisfaction and clinical outcome. Our resultssuggest that surgical division of the flexor retina-culum produces a high level of patient satisfactionin individuals with carpal tunnel syndrome. Theprecise operative factors and specialist hand teamshave not been shown in this study to yield a superiorclinical outcome.Figure 3 Boxplot showing distribution of total score byanaesthetic type.Figure 4 Boxplot showing distribution of total score bytourniquet use.A. Gulati et al.118AcknowledgementWe would like to thank the Clinical Audit Depart-ment at Ipswich Hospital for their help in datacollection.References1. Stevens JC, Sun S, Beard CM, O’Fallon WM, Kurland LT.Carpal tunnel syndrome in Rochester, Minnesota, 1961 to1980. Neurology 1988;38:134—8.2. Franklin GM, Haug J, Heyer N, Checkoway H, Peck N.Occupational carpal tunnel syndrome in Washington State,1984—1988. Am J Public Health 1991;81(6):741—6.3. Kaplan SJ, Glickel SZ, Eaton RG. Predictive factors in thenon-surgical treatment of carpal tunnel syndrome. J HandSurg 1990;15B(1):106—8.4. Learmonth JR. The principle of decompression in treatmentof certain diseases of peripheral nerves. Surg Clin North Am1933;13:905—13.5. Rege AJ, Sher JL. Can the outcome of carpal tunnel releasebe predicted? J Hand Surg 2001;26B(2):148—50.6. Dias JJ, Bhowal B, Wildin CJ, Thompson JR. Assessing theoutcome of disorders of the hand. Is the patient evaluationmeasure reliable, valid, responsive and without bias? J BoneJoint Surg 2001;83B(2):135—40.7. Macey AC, Burke FD, Abbott K, et al. Outcomes of handsurgery. British Society for Surgery of the Hand. J Hand Surg1995;20B(6):841—55.8. Katz JN, Gelberman RH, Wright EA, Abrahamsson SO, LewRA. A preliminary scoring system for assessing the outcomeof carpal tunnel release. J Hand Surg 1994;19A(4):531—8.9. Levine DW, Simmons BP, Koris W, et al. A self-administeredquestionnaire for the assessment of severity of symptomsand functional status in carpal tunnel syndrome. J Bone JointSurg 1993;75A(11):1585—92.10. Amadio PC, Silverstein MD, Ilstrup DM, Schleck CD, JensenLM. Outcome assessment for carpal tunnel surgery: therelative responsiveness of generic, arthritis-specific, dis-ease-specific, and physical examination measures. J HandSurg 1996;21A(3):338—46.11. Loefler U. The drawbacks of overspecialisation. J R Coll SurgEdinb 1999;44:11—12.12. Phalen GS. The carpal-tunnel syndrome. Seventeen years’experience in diagnosis and treatment of six hundred fifty-four hands. J Bone Joint Surg 1966;48A(2):211—28.13. Altissimi M, Mancini GB. Surgical release of the median nerveunder local anaesthesia for carpal tunnel syndrome. J HandSurg 1988;13B(4):395—6.14. Gibson M. Outpatient carpal tunnel decompression withouttourniquet: a simple local anaesthetic technique. Ann R CollSurg Engl 1990;72(6):408—9.15. Tzarnas CD. Carpal tunnel release without a tourniquet.J Hand Surg 1993;18A(6):1041—3.Carpal tunnel decompression 119

Carpal tunnel decompression. The impact of tourniquet, anaesthesia type, and operating team on patient satisfaction scores

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