1. Endoscopic versus open carpal tunnel release.
| References | Symptoms ≤ 3 months | Symptoms ≥ 3 months | Return to work / activities of daily living | Complications |
| Agee 1992 | Results of 97 adequately randomised participants with unilateral CTS not presented separately. At 3 months, 42% of ECTR and 49% of OCTR participants still had pain. 22% of ECTR and 13% of OCTR participants still had numbness. No significant differences | Results of 97 adequately randomised patients with unilateral CTS not presented separately. At 6 months, 25% of ECTR and 27% of OCTR patients still had pain. 12% of ECTR and 19% of OCTR patients still had numbness. No significant differences | Median 25 (ECTR) and 46.5 (OCTR) days (significant difference between the groups) | ECTR: re‐operation needed with OCTR in 2 of 82 participants; transient ulnar neurapraxia (2) OCTR: injury to deep motor branch of ulnar nerve (1); bowstringing of digital flexor tendons (1); wound dehiscence (2) |
| Atroshi 2006 | Mean SSS (Levine) after 3 months: ECTR 1.5; OCTR 1.5 Mean FSS (Levine) after 3 months: ECTR 1.3; OCTR 1.3 Difference in mean pain scores (0 to 100) after 3 months ‐13.3 (95% CI ‐ 21.3 to ‐5.3) in favour of ECTR |
Mean SSS (Levine) after 12 months: ECTR 1.4; OCTR 1.4 (NS). Mean FSS (Levine) after 12 months: ECTR 1.3; OCTR 1.2 (NS). Difference in mean pain scores (0 to 100) after 12 months ‐5.8 (95% CI ‐ 13.3 to ‐1.7) in favour of ECTR. Outcomes remained similar at 5 years | Not on sick leave before surgery: MD ‐5 days (95% CI ‐11.5 to 1.5 days) in favour of ECTR. On sick leave before surgery: MD 8 days (95% CI ‐62.5 to 78.5 days) in favour of OCTR. MD for all patients ‐4.89 days, 95% CI ‐11.35 to 1.57 days favours ECTR patients | Repeat surgery at 1 year: ECTR 2/63 (3%); OCTR 1/65 (2%). No other complications. Between 1 year and 5 years postoperatively. 2 participants in the open group and 1 participant in the endoscopic group had OCTR because of recurrent symptoms |
| Benedetti/Sennwald 1995 | Not assessed | Not assessed | Mean 24 (ECTR) and 42 (OCTR) days (significant difference between the groups) | 1 conversion to OCTR and 1 transient neurapraxia after ECTR. 1 painful hypertrophic scar and 1 reflex sympathetic dystrophy after OCTR |
| Brown 1993 | Improvement in symptoms (paraesthesiae, numbness) in 99% of hands (ECTR) and 98% of hands (OCTR) after 12 weeks (difference 1%, 95% CI ‐ 3% to 5%) | Not assessed | Median 14 (ECTR) and 28 (OCTR) days (significant difference between the groups) | Significantly more scar tenderness after OCTR vs ECTR after 12 weeks (no significant differences after 3 and 6 weeks). No significant differences between the groups in tenderness of the thenar eminence at 3, 6 and 12 weeks. 1 partial transection of the superficial palmar arch, 1 digital‐nerve contusion, 1 ulnar‐nerve neurapraxia and 1 wound haematoma after ECTR |
| Dumontier 1995 | Persisting paraesthesiae after 3 months: 7% (OCTR) vs 11% (ECTR). Persisting pain after 3 months: 43.3% (OCTR) vs 38.5% (ECTR) | Paraesthesiae completely disappeared in all patients after 6 months. Persisting pain after 6 months: 28% (OCTR) vs 25% (ECTR) | Percentage of participants returned to work (OCTR vs ECTR): 72% vs 45% after 1 month; 90% vs 72% after 3 months | Transient reflex sympathetic dystrophy in 4 participants (2 in each group) |
| Eichhorn 2003 | ‐ | Overall severity score (scale 1 to 6) after > 1 year: OCTR 2.2; ECTR 2.1 | ‐ | Postoperative infections: 2 after OCTR; none after ECTR Recurrences: ECTR 3/128 (2%), OCTR 4/60 (7%) Need for repeated surgery: ECTR 2/128 (2%), OCTR 3/60 (5%) |
| Erdmann 1994 | Significantly more improvement in carpal tunnel pain in favour of ECTR after 1, 2 and 4 weeks, but no significant difference between the groups after 3 months | No significant difference in carpal tunnel pain between the groups after 6 and 12 months | Mean 14 (ECTR) and 39 (OCTR) days (only participants not simultaneously operated on both hands) (significant difference between the groups) | 1 ulnar nerve paraesthesiae and 1 incomplete release after ECTR. 1 wound infection, 1 scar tethering and 5 scar hypertrophy after OCTR |
| Ferdinand 2002 | After 12 weeks better endoscopic Jebson scores (65 vs 55) | After 12 months better endoscopic Jebson scores (59 vs 48) | Not applicable (all participants had bilateral CTS) | 3 conversions to OCTR after ECTR. 1 persisting wound pain in each group. 1 persisting symptoms and 1 superficial nerve injury after OCTR |
| Foucher 1993 | No data presented | No data presented | No significant differences in time to return to work between the groups (all 17 days) | 1 algodystrophy and 2 conversions to OCTR after ECTR |
| Giele 2000 | 60% to 70% of participants preferred ECTR. Outcome scores significantly higher in the ECTR group (8.1 vs 6.1). Symptoms resolved faster in the ECTR hands in the first 12 days but the 2 methods became equally successful thereafter. 2‐point discrimination, pinch and grip strength recovered faster in the ECTR hands, but equal by the 8th week | Not assessed | ‐ | 1 death, 2 participants with no symptomatic relief, 1 in each group. 3 hands in ECTR group with 3rd web space neurapraxia and 1 in the OCTR. 2 wound dehiscences and infections in the OCTR group |
| Hoefnagels 1997 | Mean symptom severity score after 3 months: 1.6 ± 0.7 after ECTR; 1.5 ± 0.5 after OCTR (no significant difference) | Not assessed | Longer than 4 weeks' absence from work in 16% (ECTR); 13% (OCTR) (difference 3%, 95% CI ‐ 7 to 14) | Significantly less postoperative pain after ECTR vs OCTR after 1 week. 1 conversion to OCTR, 1 broken knife left in operation wound and 1 increased numbness in fingertips after ECTR |
| Incoll 2004 | All participants preferred the ECTR side at 1, 2 and 6 weeks. ECTR was associated with less pain, greater ease of use, improved strength and better motion | Not assessed | Not assessed | Not assessed |
| Jacobsen 1996 | Not assessed | Not assessed | Mean 17 (ECTR) and 19 (OCTR) days (no significant difference between the groups) | 3 transient numbness on the radial side of the ring finger after ECTR. 1 prolonged wound secretion after OCTR |
| Koskella 1996 | Not presented | Not presented | The patients undergoing ECTR tended to regain functional use of their operated hand slightly sooner than the group undergoing OCTR | 1 incomplete release in the ECTR group whose symptoms improved after subsequent OCTR |
| Macdermid 2003 | After 12 weeks no significant differences in pain (McGill) (8 vs 12), SSS (Levine) (1.8 vs 2.0) and functional status (SF‐36) (47 vs 42) | After a mean of 3.2 years lower satisfaction scores after ECTR (85% vs 93%) | No significant differences (no quantitative data presented) | No complications reported. Within 4 years, in 5% of the ECTR participants, re‐operation needed |
| Malhotra 2007 | At 1 month, the incidence of local pain and scar tenderness was significantly higher in OCTR (20/31 reported mild local pain and 19 reported scar tenderness as compared to only 3 participants who reported local pain in the ECTR). 17/30 and 14/31 in ECTR and OCTR group respectively reported early relief (in 3 days) | At 6 months, no differences in grip strength. No differences could be noted from electrophysiological examination | Average time to return to daily activities was 16 days for ECTR and 20 days for OCTR | Scar tenderness in 9 OCTR participants. No incision site‐related complication in the ECTR group. 2 in the OCTR group had symptoms consistent with reflex sympathetic dystrophy, none in the ECTR group |
| Saw 2003 | Area under the curve analysis of SSS (Levine) after 3 months: ECTR 120 (IQR 21); OCTR 119 (IQR 19) (P = 0.70). Area under the curve analysis of FSS (Levine) after 3 months: ECTR 109 (IQR 22); OCTR 108 (IQR 24) (P = 0.98) | ‐ | Mean (SD) days off work ECTR 18 (11); OCTR 26 (14) (MD ‐8, 95% CI ‐13 to ‐2) | ECTR: 1 transient numbness index finger, 1 superficial wound infection, 1 repeat surgery. OCTR: 1 hyperaesthesia over scar area, 1 superficial wound infection, 1 superficial haematoma, 1 persistence of symptoms |
| Schäfer 1996 | Not assessed | All outcomes measured at 9 months postoperatively. Night pain disappeared in both groups. Thenar atrophy was present in 17% and 15% of the participants in the OCTR and ECTR groups respectively. The means for the OCTR and ECTR groups were: grip strength 19.9 Kp vs 21 Kp, 2‐point discrimination tests 3.2 mm vs 3.1 mm | Mean days off work: ECTR 4.9 weeks; OCTR 5.7 weeks | No complications reported |
| Sørensen 1997 | No differences in terms of pain and disappearance of paraesthesia. Earlier return of grip strength (significant in 1, 2 and 3 weeks) and wrist motion (significant at 1 and 3 weeks) in the ECTR group | Sick leave tended to be shorter after ECTR (not significant) | Pillar pain less frequent in the ECTR group (significant at 6 weeks) |
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| Stark 1996 | Matched pairs. Pain completely relieved in 20/20 (ECTR) vs 15/20 hands (OCTR) after 3 months. Persisting paraesthesiae in 1/20 (ECTR) vs 1/20 (OCTR) after 3 months | Matched pairs. Pain completely relieved in 20/20 hands (ECTR) vs 19/20 hands (OCTR) after 8 months. Persisting paraesthesiae in 1/20 hands (ECTR) vs 1/20 hands (OCTR) after 8 months | Mean 20 (ECTR) vs 30 (OCTR) days (significant difference between the groups) | 1 subcutaneous hematoma and 1 loss of strength and mobility in the wrist after ECTR. 2 loss of strength and 1 swollen/stiff fingers after OCTR |
| Tian 2007 | Rate of scar tenderness: ECTR 36%, OCTR 65% (significant). No differences in 2‐point discrimination. Operation time was shorter in ECTR group (12 min vs 38 min) | Not assessed | Time to return to work: ECTR 12 days, OCTR 28 days (P < 0.01) | 3 participants in ECTR group did not improve and they underwent OCTR (final outcome for those participants not mentioned) |
| Trumble 2002 | After 12 weeks, better scores for satisfaction (4.4 vs 4.0, non‐significant), SSS (Levine) (1.8 vs 2.5, significant) and FSS (Levine) (1.7 vs 2.4, significant) | After 12 months, no significant differences for satisfaction (4.6 vs 4.5), SSS (Levine) (1.8 vs 1.8) and FSS (Levine) (1.7 vs 1.7) | Median 18 days (ECTR) and 38 days (OCTR) (significant difference between the groups) | After OCTR, 2 reflex sympathetic dystrophy and 1 repeat procedure (no complications after ECTR) |
| Tüzüner 2008 | Longitudinal excursion and volar displacement of the median nerve were calculated. No statistically significant difference in pre‐ and post‐release longitudinal excursion changes between ECTR and OCTR groups | Not assessed | Not assessed | Not assessed |
| Werber 1996 | Not assessed | Not assessed | Patients with ECTR returned earlier to work and had less pain | No nerve, tendon or vessel lesions were observed. 2 participants in the ECTR group reported paraesthesias in the ulnar nerve. In 8 participants, the endoscopic method had to be changed into open procedure |
| Westphal 2000 | SSS (variant of Levine) after 3 months: ECTR 11.0 (3.7); OCTR 10.6 (2.6) Mean FSS (variant of Levine) after 3 months: ECTR 10.2 (4.5); OCTR 9.8 (4.4) |
‐ | Mean 34.5 days (ECTR) vs 36 days (OCTR) (no significant difference between the groups) |
3 patients in each group had tenderness at 3 months |
ECTR: endoscopic carpal tunnel release; FSS: Functional Status Score; IQR: interquartile range; OCTR: open carpal tunnel release; SSS: Symptom Severity Score