Vasiliadis Haris S, Georgoulas Petros, Shrier Ian, Salanti Georgia, Scholten Rob J P M
Department of Orthopaedics, University of Ioannina, Ioannina, Greece.
Cochrane Database Syst Rev. 2014 Jan 31;2014(1):CD008265. doi: 10.1002/14651858.CD008265.pub2.
Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. It is caused by increased pressure on the median nerve between the transverse carpal ligament and the carpal bones. Surgical treatment consists of the release of the nerve by cutting the transverse carpal ligament. This can be done either with an open approach or endoscopically.
To assess the effectiveness and safety of the endoscopic techniques of carpal tunnel release compared to any other surgical intervention for the treatment of CTS. More specifically, to evaluate the relative impact of endoscopic techniques in relieving symptoms, producing functional recovery (return to work and return to daily activities) and reducing complication rates.
This review fully incorporates the results of searches conducted up to 5 November 2012, when we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. There were no language restrictions. We reviewed the reference lists of relevant articles and contacted trial authors. We also searched trial registers for ongoing trials. We performed a preliminary screen of searches to November 2013 to identify any additional recent publications.
We included any randomised controlled trials (RCTs) and quasi-RCTs comparing endoscopic carpal tunnel release (ECTR) with any other surgical intervention for the treatment of CTS.
We used standard methodological procedures expected by the Cochrane Collaboration.
Twenty-eight studies (2586 hands) were included. Twenty-three studies compared ECTR to standard open carpal tunnel release (OCTR), five studies compared ECTR with OCTR using a modified incision, and two studies used a three-arm design to compare ECTR, standard OCTR and modified OCTR.At short-term follow-up (three months or less), only one study provided data for overall improvement. We found no differences on the Symptom Severity Scale (SSS) (scale zero to five) (five studies, standardised mean difference (SMD) -0.13, 95% CI -0.47 to 0.21) or on the Functional Status Scale (FSS) (scale zero to five) (five studies, SMD -0.23, 95% CI -0.60 to 0.14) within three months postoperatively between ECTR and OCTR. Pain scores favoured ECTR over conventional OCTR (two studies, SMD -0.41, 95% CI -0.65 to -0.18). No difference was found between ECTR and OCTR (standard and modified) when pain was assessed on non-continuous dichotomous scales (five studies, RR 0.69, 95% CI 0.33 to 1.45). Also, no difference was found in numbness (five studies, RR 1.14; 95% CI 0.76 to 1.71). Grip strength was increased after ECTR when compared with OCTR (six studies, SMD 0.36, 95% CI 0.09 to 0.63). This corresponds to a mean difference (MD) of 4 kg (95% CI 1 to 6.9 kg) when compared with OCTR, which is probably not clinically significant.In the long term (more than three months postoperatively) there was no significant difference in overall improvement between ECTR and OCTR (four studies, RR 1.04, 95% CI 0.95 to 1.14). SSS and FSS were also similar in both treatment groups (two studies, MD 0.02, 95% CI -0.18 to 0.22 for SSS and MD 0.01, 95% CI -0.14 to 0.16 for FSS). ECTR and OCTR did not differ in the long term in pain (six studies, RR 0.88, 95% CI 0.57 to 1.38) or in numbness (four studies, RR 0.64, 95% CI 0.31 to 1.35). Results from grip strength testing favoured ECTR (two studies, SMD 1.13, 95% CI 0.56 to 1.71), corresponding to an MD of 11 kg (95% CI 6.2 to 18.81). Participants treated with ECTR returned to work or daily activities eight days earlier than participants treated with OCTR (four studies, MD -8.10 days, 95% CI -14.28 to -1.92 days).Both treatments were equally safe with only a few reports of major complications (mainly with complex regional pain syndrome) (15 studies, RR 1.00, 95% CI 0.38 to 2.64).ECTR resulted in a significantly lower rate of minor complications (18 studies, RR 0.55, 95% CI 0.38 to 0.81), corresponding to a 45% relative drop in the probability of complications (95% CI 62% to 19%). ECTR more frequently resulted in transient nerve problems (ie, neurapraxia, numbness, and paraesthesiae), while OCTR had more wound problems (ie, infection, hypertrophic scarring, and scar tenderness). ECTR was safer than OCTR when the total number of complications were assessed (20 studies, RR 0.60, 95% CI 0.40 to 90) representing a relative drop in the probability by 40% (95% CI 60% to 10%).Rates of recurrence of symptoms and the need for repeated surgery were comparable between ECTR and OCTR groups.The overall risk of bias in studies that contribute data to these results is rather high; fewer than 25% of the included studies had adequate allocation concealment, generation of allocation sequence or blinding of the outcome assessor.The quality of evidence in this review may be considered as generally low. Five of the studies were presented only as abstracts, with insufficient information to judge their risk of bias. In selection bias, attrition bias or other bias (baseline differences and financial conflict of interest) we could not reach a safe judgement regarding a high or low risk of bias. Blinding of participants is impossible due to the nature of interventions.We identified three further potentially eligible studies upon updating searches just prior to publication. These compared ECTR with OCTR (two studies) or mini-open carpal tunnel release (one study) and will be fully assessed when we update the review.
AUTHORS' CONCLUSIONS: In this review, with support from low quality evidence only, OCTR and ECTR for carpal tunnel release are about as effective as each other in relieving symptoms and improving functional status, although there may be a functionally significant benefit of ECTR over OCTR in improvement in grip strength. ECTR appears to be associated with fewer minor complications compared to OCTR, but we found no difference in the rates of major complications. Return to work is faster after endoscopic release, by eight days on average. Conclusions from this review are limited by the high risk of bias, statistical imprecision and inconsistency in the included studies.
腕管综合征（CTS）是上肢最常见的压迫性神经病变。它是由腕横韧带与腕骨之间的正中神经受压增加所致。手术治疗包括通过切断腕横韧带松解神经。这可以通过开放手术或内镜手术来完成。
评估与其他任何手术干预相比，内镜下腕管松解技术治疗CTS的有效性和安全性。更具体地说，评估内镜技术在缓解症状、实现功能恢复（恢复工作和恢复日常活动）以及降低并发症发生率方面的相对影响。
本综述全面纳入了截至2012年11月5日进行的检索结果，当时我们检索了Cochrane神经肌肉疾病组专业注册库、Cochrane系统评价数据库、医学期刊数据库（MEDLINE）和荷兰医学文摘数据库（EMBASE）。没有语言限制。我们查阅了相关文章的参考文献列表并联系了试验作者。我们还检索了试验注册库以查找正在进行的试验。我们对截至2013年11月的检索进行了初步筛选，以识别任何其他近期出版物。
我们纳入了任何比较内镜下腕管松解术（ECTR）与其他任何手术干预治疗CTS的随机对照试验（RCT）和半随机对照试验。
我们采用了Cochrane协作网期望的标准方法程序。
纳入了28项研究（2586只手）。23项研究将ECTR与标准开放腕管松解术（OCTR）进行了比较，5项研究将ECTR与采用改良切口的OCTR进行了比较，2项研究采用三臂设计比较了ECTR、标准OCTR和改良OCTR。在短期随访（三个月或更短时间）时，只有一项研究提供了总体改善的数据。我们发现在术后三个月内，ECTR与OCTR在症状严重程度量表（SSS）（0至5分）（五项研究，标准化均数差（SMD）-0.13，95%可信区间-0.47至0.21）或功能状态量表（FSS）（0至5分）（五项研究，SMD -0.23，95%可信区间-0.60至0.14）上没有差异。疼痛评分显示ECTR优于传统OCTR（两项研究，SMD -0.41，95%可信区间-0.65至-0.18）。当在非连续二分法量表上评估疼痛时，ECTR与OCTR（标准和改良）之间没有差异（五项研究，相对危险度（RR）0.69，95%可信区间0.33至1.45）。此外，在麻木方面也没有差异（五项研究，RR 1.14；95%可信区间0.76至1.71）。与OCTR相比，ECTR后握力增加（六项研究，SMD 0.36，95%可信区间0.09至0.63）。与OCTR相比，这相当于平均差异（MD）为4千克（95%可信区间1至6.9千克），这可能在临床上不具有显著意义。在长期（术后三个月以上），ECTR与OCTR在总体改善方面没有显著差异（四项研究，RR 1.04，95%可信区间0.95至1.14）。两个治疗组的SSS和FSS也相似（两项研究，SSS的MD为0.02，95%可信区间-0.18至0.22；FSS的MD为0.01，95%可信区间-0.14至0.16）。ECTR和OCTR在长期疼痛（六项研究，RR 0.88，95%可信区间0.57至1.38）或麻木（四项研究，RR 0.64，95%可信区间0.31至1.35）方面没有差异。握力测试结果支持ECTR（两项研究，SMD 1.13，95%可信区间0.56至1.71），相当于MD为11千克（95%可信区间6.2至18.81）。接受ECTR治疗的参与者比接受OCTR治疗的参与者提前八天恢复工作或日常活动（四项研究，MD -8.10天，95%可信区间-14.28至-1.92天）。两种治疗同样安全，只有少数关于严重并发症的报告（主要是复杂性区域疼痛综合征）（15项研究，RR 1.00，95%可信区间0.38至2.64）。ECTR导致的轻微并发症发生率显著较低（18项研究，RR 0.55，95%可信区间0.38至0.81），相当于并发症发生概率相对下降45%（95%可信区间62%至19%）。ECTR更频繁地导致短暂性神经问题（即神经失用、麻木和感觉异常），而OCTR有更多的伤口问题（即感染、肥厚性瘢痕和瘢痕压痛）。当评估并发症总数时，ECTR比OCTR更安全（20项研究，RR 0.60，95%可信区间0.40至0.90），代表发生概率相对下降40%（95%可信区间60%至10%）。ECTR和OCTR组之间症状复发率和再次手术的需求相当。为这些结果提供数据的研究中总体偏倚风险相当高；纳入的研究中不到25%有充分的分配隐藏、分配序列产生或结果评估者的盲法。本综述中的证据质量一般可认为较低。五项研究仅以摘要形式呈现，信息不足无法判断其偏倚风险。在选择偏倚、失访偏倚或其他偏倚（基线差异和利益冲突）方面，我们无法就高或低偏倚风险做出可靠判断。由于干预的性质，参与者的盲法是不可能的。在发表前更新检索时，我们确定了另外三项可能符合条件的研究。这些研究将ECTR与OCTR（两项研究）或小切口开放腕管松解术（一项研究）进行了比较，当我们更新综述时将对其进行全面评估。
在本综述中，仅在低质量证据的支持下，OCTR和ECTR用于腕管松解在缓解症状和改善功能状态方面效果相当，尽管ECTR在改善握力方面可能比OCTR有功能上的显著益处。与OCTR相比，ECTR似乎与较少 的轻微并发症相关，但我们发现严重并发症发生率没有差异。内镜松解后平均提前八天恢复工作。本综述的结论受到纳入研究中高偏倚风险、统计不精确性和不一致性的限制。
