Abstract
Introduction
Carpal Tunnel Syndrome (CTS) is a painful orthopedic hand condition caused by compression of the median nerve at the wrist. Diagnosis is typically clinical, relying on patient’s symptoms and physical examination findings, but confirmation often requires electrodiagnostic studies. Previous research on CTS has explored the relationship between median nerve compression severity and various outcomes. However, these studies have been limited by short follow-up durations, small to modest patient cohorts, and a narrow focus on patient-reported outcomes. The objective of this study was to provide a long-term, 10-year follow-up with a relatively large patient cohort, focusing on new patient-reported outcomes and their association with the severity of nerve compression.
Methods
A retrospective cohort study was conducted on a total of 581 patients who underwent open carpal tunnel release surgery between 2013 and 2023 at a major teaching hospital in Jordan. Severity was categorized based on nerve conduction study results into three groups: mild, moderate, and severe and Six distinct outcomes of interest were examined.
Results
No significant differences in age, health profiles, comorbidities, or disease presentation were observed among the severity groups. However, significant variations were found across the six outcomes. Patients with severe disease had longer recovery times (p < 0.01), less pain relief (p = 0.03), reduced satisfaction (p = 0.04), diminished functional improvement (p < 0.01), lower ADL improvement (p < 0.01), yet experienced better sleep quality improvement (p < 0.01).
Conclusion
Long-term follow-up post-open carpal tunnel release surgery revealed that severe cases experienced longer recovery times, less pain relief, reduced satisfaction, diminished functionality improvement, and lower ADL improvement, but better sleep quality.
Level of evidence
Level III, Retrospective cohort study.
Keywords: Carpal tunnel syndrome, Hand pain, Hand function, Nerve conduction study, Severity classification, Electrodiagnostic testing
Introduction
Carpal tunnel syndrome (CTS) stands as one of the most prevalent compression neuropathies worldwide, primarily affecting the median nerve as it traverses the carpal tunnel at the wrist [1–3]. It manifests through a spectrum of symptoms including pain, numbness, tingling, and weakness in the hand and fingers, often exacerbated during activities involving wrist flexion or extension [4, 5]. The etiology of CTS typically involves a combination of intrinsic factors such as anatomical variations in carpal tunnel dimensions, inflammation, and extrinsic factors like repetitive hand motions or trauma [6]. As a result, CTS poses significant challenges to both patients and healthcare systems, leading to functional impairment, diminished quality of life, and economic burden [7].
Diagnosis of CTS typically relies on a combination of clinical assessment and electrodiagnostic studies. The hallmark clinical features of CTS include sensory disturbances in the median nerve distribution [8]. However, electrodiagnostic studies, particularly nerve conduction studies (NCS), play a crucial role in confirming the diagnosis and assessing disease severity [9–11]. NCS provides objective measures of nerve function by evaluating the latency, amplitude, and velocity of nerve conduction, aiding in the differentiation of CTS from other neuropathies and guiding treatment decisions [12]. Initial management often involves conservative measures such as wrist splinting, activity modification, and corticosteroid injections. However, in cases refractory to conservative therapy or with severe symptoms, surgical decompression of the carpal tunnel may be necessary to alleviate pressure on the median nerve [13].
Although carpal tunnel syndrome can often be diagnosed clinically, the nerve conduction study (NCS) plays a crucial role in the diagnostic process, providing valuable confirmation and insights into nerve function and the severity of nerve damage [14, 15]. With both diagnostic and prognostic aspects, NCS enhances the diagnostic workup of carpal tunnel syndrome by offering objective measures and comprehensive evaluation of nerve function [16]. Furthermore, NCS aids in stratifying patients based on disease severity, guiding treatment decisions, and predicting outcomes following intervention [10].
Although the diagnostic value of Nerve Conduction Studies (NCS) in evaluating Carpal Tunnel Syndrome (CTS) is widely recognized, its correlation with Patient-Reported Outcomes (PROs) has not been fully explored in previous studies. These studies have typically had a limited follow-up duration of up to 5 years and have employed restricted outcome measures. In contrast, our study introduces important new outcomes of interest and extends the follow-up period to 10 years. Our research aims to offer new insights into the clinical significance of NCS findings by demonstrating how objective measures of nerve dysfunction align with patients’ subjective experiences.
Patients and methods
Participants
The research comprised 581 individuals who received surgical treatment for carpal tunnel syndrome (CTS) under local anesthesia. This cohort consisted of patients who underwent surgery at a prominent teaching tertiary hospital in Jordan after being diagnosed with carpal tunnel syndrome between 2013 and 2023.
Study design and research objectives
In our retrospective cohort study, we aimed to assess the association between the severity of nerve conduction study (NCS) findings and six patient-reported outcomes (PROs) in individuals who underwent surgical treatment for carpal tunnel syndrome (CTS). The primary objective of our study was to assess how NCS severity influences post-surgery patient-reported outcomes (PROs), encompassing recovery time in months, self-reported pain relief (rated from 0 to 10), satisfaction level (rated from 0 to 10), functionality improvement (rated from 0 to 10), ability to perform activities of daily living (rated from 0 to 10), and sleep quality improvement (rated from 0 to 10). Furthermore, secondary outcomes were explored, including patients’ health profiles, symptom presentations, and preoperative treatments received.
Outcome variables definitions
Recovery time in months
The duration it takes for patients to fully recover from carpal tunnel syndrome surgery, measured in months from the date of the operation. It reflects the time required for patients to regain their pre-operative level of function and symptom relief.
Self-reported pain relief (0–10)
A subjective assessment provided by patients to quantify the extent of pain alleviation they experience following surgery. Patients rate their pain relief on a scale from 0 (indicating no relief) to 10 (indicating complete relief), based on their perceived reduction in pain intensity compared to pre-surgery levels.
Satisfaction level (0–10)
An individual’s subjective rating of their overall satisfaction with the outcome of carpal tunnel surgery. Patients rate their satisfaction on a scale from 0 (representing complete dissatisfaction) to 10 (representing complete satisfaction), reflecting their perception of the surgery’s effectiveness and impact on their quality of life.
Functionality improvement (0–10)
The perceived enhancement in patients’ functional abilities following surgery. This measure assesses the degree of improvement in job-related, routine-work-related tasks and activities. Patients rate their functionality improvement on a scale from 0 (no improvement) to 10 (significant improvement), based on their perceived increase in functional capacity post-surgery.
Ability to perform activities of daily living (0–10)
Patients’ self-reported ability to engage in routine daily activities following surgery. This measure evaluates the extent to which patients can independently carry out activities essential for daily living. Patients rate their ability on a scale from 0 (unable to perform any activities) to 10 (able to perform all activities without difficulty), reflecting their perceived level of functional independence.
Sleep quality improvement (0–10)
Patients’ perception of improvement in sleep quality after undergoing carpal tunnel surgery. This measure assesses changes in sleep patterns and experiences following surgical intervention. Patients rate their sleep quality improvement on a scale from 0 (indicating no improvement in sleep quality) to 10 (indicating significant improvement), based on their subjective assessment of sleep-related changes post-surgery.
Study protocol
Patients who underwent carpal tunnel release surgery under local anesthesia between January 2013 and December 2023 were included in the study cohort. Following the application of specific eligibility criteria, eligible participants were recruited for the study. The surgical procedure was conducted by skilled hand surgeons using a standardized technique. Before the surgery, all eligible participants underwent preoperative assessment, which included clinical examination and electrodiagnostic studies, specifically nerve conduction studies (NCS). These NCS evaluations were conducted within one month prior to the surgery at the same hospital by a specialized neuroscience and electrophysiology unit and were interpreted by the same consultant neurologist.
Electrodiagnostic testing and assessment of NCS
Nerve conduction studies (NCS) were performed preoperatively to evaluate the severity of median nerve dysfunction in patients with CTS. NCS parameters including sensory and motor nerve conduction velocities, amplitudes, and latencies were measured using standardized techniques. The classification of NCS abnormalities into severity categories is based on specific electrophysiological parameters [17, 18]:
Mild CTS
characterized by an increased sensory latency of greater than 3.5 milliseconds (ms) or a decreased sensory conduction velocity of less than 40 m per second (m/s), with a normal motor response of the median nerve.
Moderate CTS
indicated by an increased sensory latency along with a decreased amplitude, and an increased motor latency of greater than 4.5 ms.
Severe CTS
defined by a motor latency greater than 4.5ms with an absent sensory response.
Inclusion and exclusion criteria
The study specifically included individuals meeting the following criteria: a clinical diagnosis of isolated carpal tunnel syndrome (CTS) confirmed by electrodiagnostic studies, aged 18 years or older, and underwent carpal tunnel release surgery under local anesthesia between January 2013 and December 2023. Exclusion criteria encompassed individuals with concurrent upper extremity neuropathies, a history of previous hand trauma or fractures, systemic neuropathies, combined hand surgeries in addition to carpal tunnel release, revision or endoscopic procedures, incomplete health records, or those who declined to participate. Figure 1 is a flowchart summarizing the study methodology.
Fig. 1.
Flowchart summarizing the study methodology
Ethical considerations
Appropriate Institutional Review Board (IRB) for this study was obtained by the Jordan University Medical Research Office, IRB number (2023/25128). Informed consent was obtained from all participants prior to enrollment, and measures were taken to ensure patient confidentiality and privacy throughout the study. The Code of Ethics of the World Medical Association (Declaration of Helsinki) was followed while conducting the study.
Data collection and analysis
Demographic, clinical, and treatment data were collected retrospectively and entered into a secure electronic database. The data collection process involved postoperative follow-up visits, phone calls, and authorized access to patients’ health records. Descriptive statistics were used to summarize patient characteristics and patient-reported outcomes (PROs). The relationship between NCS severity and PROs was analyzed using appropriate statistical methods, including the ANOVA test to compare means across the three severity categories and the chi-square test for analyzing categorical variables. A statistical significance level of p < 0.05 was set to determine significant findings.
Results
In our investigation comprising 681 patients diagnosed with carpal tunnel syndrome (CTS), symptoms were classified into three categories: mild, moderate, and severe. Out of the total patients, 122 (17.9%) experienced mild symptoms, 385 (52.3%) experienced moderate symptoms, and 203 (29.8%) experienced severe symptoms.
Among the 681 patients, the mean age of the participants was 51.6 years, and the mean BMI was 31.67. The majority of participants were non-smokers (82%) (Table 1). Among participants reporting any symptoms, females significantly constituted the majority across all severity levels (mild: 72.9%, moderate: 59%, severe: 61.5%). These findings are further detailed in Table 2.
Table 1.
Summary of patient’s characteristics
| Comparison | Mild (n = 122) n |
Moderate (n = 365) n |
Severe (n = 203) n |
p-value | |
|---|---|---|---|---|---|
| Gender | Male | 33 | 69 | 53 | 0.08 |
| Female | 89 | 287 | 150 | ||
| Side | Right | 80 | 216 | 125 | 0.62 |
| Left | 42 | 140 | 78 | ||
| Handedness | Right | 111 | 329 | 191 | 0.56 |
| Left | 11 | 27 | 12 | ||
| Smoking status | Yes | 21 | 61 | 40 | 0.73 |
| No | 101 | 295 | 163 | ||
| Hypertension | Yes | 48 | 132 | 82 | 0.72 |
| No | 74 | 224 | 121 | ||
| Diabetes mellitus | Yes | 36 | 109 | 74 | 0.28 |
| No | 86 | 247 | 129 | ||
| Cardiovascular disease | Yes | 17 | 43 | 33 | 0.38 |
| No | 105 | 313 | 170 | ||
| Rheumatological disease | Yes | 14 | 31 | 18 | 0.64 |
| No | 108 | 325 | 185 | ||
| Renal disease | Yes | 2 | 13 | 9 | 0.41 |
| No | 120 | 343 | 194 | ||
|
Comparison (means) |
Mild (n = 122) |
Moderate (n = 365) |
Severe (n = 203) |
p -value | |
| Age (yrs.) | 51 | 52 | 52 | 0.41 | |
| BMI (kg/m2) | 34 | 31 | 30 | 0.17 | |
Table 2.
Comparison between the groups in clinical presentation and treatment received
| Comparison | Mild (n = 122) n |
Moderate (n = 365) n |
Severe (203) n |
p-value | |
|---|---|---|---|---|---|
| Night symptoms | Yes | 102 | 310 | 179 | 0.48 |
| No | 20 | 46 | 24 | ||
| Subjective grip weakness | Yes | 93 | 282 | 157 | 0.75 |
| No | 29 | 74 | 46 | ||
| CS injections | Yes | 21 | 52 | 26 | 0.55 |
| No | 101 | 304 | 177 | ||
| Night splint use | Yes | 41 | 134 | 63 | 0.27 |
| No | 81 | 222 | 140 | ||
| Gabapentin use | Yes | 36 | 87 | 44 | 0.28 |
| No | 86 | 269 | 159 | ||
|
Comparison (means) |
Mild (n = 122) |
Moderate (n = 365) |
Severe (n = 203) |
p -value | |
| Self-reported disability (/10) | 6.9 | 7.4 | 7.9 | 0.12 | |
| Duration of symptoms (mo.) | 4.2 | 3.8 | 3.4 | 0.23 | |
Table 2 Outlines the relationship between severity categories and clinical presentation. While night symptoms were observed across all severity categories, with higher numbers in moderate and severe groups, these differences did not reach statistical significance. Similarly, subjective grip weakness showed no substantial variance between patients across the severity categories, with no statistically significant difference observed (p = 0.75). Additionally, no significant discrepancies were noted among the groups regarding steroid injection use, night splint utilization, Gabapentin use, reported disability, and symptom duration. Further details can be found in Table 2.
Our study’s key comparison outcomes yielded significant outcomes, revealing a mostly consistent pattern across the three severity categories in terms of outcome variables. Patients in the severe group displayed fewer improvements than those in the mild and moderate groups. However, an exception was seen in the improved sleep quality, which exhibited the most significant improvement within the severe group. The differences in all the outcomes of interest - recovery time, self-reported pain relief, functionality improvement, improvement in activities of daily living (ADLs), and sleep quality - were statistically significant. This was evidenced by the respective p-values of < 0.01, 0.03, 0.04, < 0.01, < 0.01, and < 0.01 as shown in Table 3. Figure 2 is a bar-chart visualization of the outcomes of interest results.
Table 3.
Comparison of outcomes of interest across the three study groups, with values of statistical significance (p < 0.05) denoted by an asterisk (*) and bolded
| Comparison | Mild (n = 122) n (%) |
Moderate (n = 365) n (%) |
Severe (203) n (%) |
p-value |
|---|---|---|---|---|
| Recovery time (mo.) | 2.2 | 3.4 | 6.5 | < 0.01* |
| Self-reported pain relief (/10) | 8.4 | 8.0 | 7.3 | 0.03* |
| Self-reported Satisfaction (/10) | 8.5 | 7.5 | 6.9 | 0.04* |
| Functionality improvement (/10) | 8.9 | 8.4 | 6.9 | < 0.01* |
| Improvement in ADLs (/10) | 9.0 | 7.9 | 7.5 | < 0.01* |
| Improvement in sleep quality (/10) | 8.1 | 7.8 | 9.1 | < 0.01* |
Fig. 2.
Bar chart illustration of the outcome variables of interest with their corresponding p-values across the three severity groups
Discussion
While numerous prior studies have explored the connection between carpal tunnel syndrome severity, as indicated by nerve conduction studies, and certain patient-reported outcomes, our study delved into different aspects of the spectrum of patient-reported outcomes. Previous studies on this topic varied in their follow-up times, ranging from 3 months postoperatively to up to 5 years. However, our study extended the follow-up period to 10 years, adding significant value to our findings. Moreover, most prior studies focused solely on symptom improvement, such as pain and paresthesia, or occasionally utilized simplistic questionnaires like the Disabilities of the Arm, Shoulder, and Hand (DASH) or the Michigan Hand Outcomes Questionnaire. None have investigated improvements in sleep quality patterns, activities of daily living (ADLs), and recovery time to the extent that our study has.
Although the diagnosis of carpal tunnel syndrome can often be made based on the patient’s history and physical examination findings, the integration of nerve conduction studies into the diagnostic process is vitally important. Nerve conduction studies provide the sole means of objectively assessing the degree of median nerve compression in the carpal tunnel. Numerous studies have established that this information has not just diagnostic value, but prognostic significance as well [19–23].
Previous research has evaluated outcomes following carpal tunnel release surgery, albeit with varying follow-up durations. For instance, Ozkul et al. conducted a 1-year follow-up study comparing outcomes in diabetic and non-diabetic carpal tunnel patients [24]. Atroshi et al. carried out a 5-year follow-up post-surgery, comparing the open and endoscopic techniques [25]. Similarly, Weber et al. also conducted a 5-year follow-up, but their study was confined to geriatric patients with carpal tunnel syndrome [26]. Jing-bo Liu et al. also followed up for 5 years post-surgery, but their study was limited to a small sample size of 56 patients with late-stage disease and muscle atrophy [27]. Furthermore, Tang et al. performed a 9-year follow-up, but their patient cohort was restricted to those with severe disease [28]. De Kleermaeker et al. also conducted a 9-year follow-up, but their cohort included only 87 patients [29].
However, to our knowledge, no prior studies have investigated a large patient cohort over a 10-year period, similar to our study. This makes our research unique and adds substantial value to the existing body of literature. The extended follow-up period in our study provides a more comprehensive understanding of the long-term patient-centered outcomes following carpal tunnel release surgery, thereby offering new insights into this field.
Previous studies examining outcomes in carpal tunnel syndrome based on nerve conduction study severity have explored various aspects of patient-reported outcomes, encompassing satisfaction levels, symptom resolution, and scoring systems for hand symptoms and functions (Table 4). However, to the best of our knowledge, no prior research has investigated the recovery time in months or improvements in sleep quality pattern across various severity. Our study contributes to addressing this gap by providing novel insights into these crucial aspects of patient recovery following carpal tunnel release surgery.
Table 4.
Summary of literature reviews comparing outcomes in patients undergoing carpal tunnel release surgery, categorized by electrophysiological classification of severity
| Previous studies | Outcomes measured | Notes |
|---|---|---|
| Bland et al. (2001)[22] | Five-point rating scale | The five-point rating scale was patient reporting (cured, much better, better, unchanged, or worse). |
| Kronlage et al. (2015)[33] | Carpal Tunnel Symptoms Scale score | This score focusses on symptoms related to CTS like pain and numbness. |
| Conzen et al. (2016) [34] | FLZ QoL questionnaire, Modified BQ, Pain score. | Outcomes focused on symptoms and function of the affected hand as well as measures of well-being and subjective quality of life |
| Tang et al. (2017)[28] | Numbness resolution, the Boston Carpal Tunnel Questionnaire (BCTQ) score, and patient satisfaction. | The Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) is a lengthy assessment tool for individuals with carpal tunnel syndrome (CTS) in terms of symptoms, severity, and functional disability. |
| Ise et al. (2021) [16] | DASH score and Grip strength | The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire comprises 30 items assessing upper extremity activity performance. and utilizes a 5-point Likert scale |
| Matsis et al. (2021)[35] | Author-generated questionnaire | Questionnaires focus on the patient’s satisfaction and whether surgery has met the patient’s expectations. |
| Dagtas et al. (2022) [36] | Michigan Hand Outcomes Questionnaire scores | The Michigan Hand Outcomes Questionnaire (MHQ) assesses health state domains in patients with hand disorders. It measures symptoms, aesthetics, and satisfaction related to hand and upper extremity conditions and diseases. |
Previous studies have shown improved sleep quality in patients with carpal tunnel syndrome, yet no prior research has linked these improvements to specific severity classes [30–32]. In our study, patients with severe carpal tunnel syndrome, despite exhibiting suboptimal improvements in other dimensions of patient-reported outcomes such as pain relief, satisfaction, and activities of daily living (ADLs), demonstrated the greatest enhancement in sleep quality. This phenomenon could be partially attributed to the fact that patients with severe conditions experience the most intense nerve compression and consequently, the most severe symptoms before surgery. Surgical intervention, by alleviating this pressure on the median nerve, can contribute to a reduction in symptoms postoperatively. The transition from a severe preoperative state to a postoperative status, although not evidently reflected in other patient-reported outcomes, is primarily manifested in the alleviation of night symptoms and enhancement of sleep quality.
However, while this improvement in sleep quality was significant, it may not have been as apparent in other dimensions of patient-reported outcomes. This underscores the need for further research to delve deeper into this issue and elucidate the underlying pathophysiological explanation for this observation. Future studies should aim to explore this phenomenon in greater detail, providing insights into the mechanisms driving the improvement in sleep quality following surgical intervention for severe carpal tunnel syndrome.
Although our study yielded meaningful conclusions, we acknowledge several limitations. Firstly, 356 patients were excluded from the cohort primarily due to lost follow-up or incomplete health records. Including these patients could strengthen the findings and enhance the power of our study. Secondly, the retrospective nature of our study poses inherent limitations. Additionally, unlike previous studies, we did not implement hand questionnaires. Instead, our aim was to track the effects of severity-based classification on the six outcomes of interest and avoid duplicating existing literature.
One more limitation of our study is the exclusive reliance on subjective patient-reported outcomes (PROs) without incorporating objective functional assessments, such as EMG follow-up, two-point discrimination (2PD), Semmes-Weinstein monofilament (SWM) testing, and thenar muscle strength recovery. While PROs offer valuable insights into the patient’s perception of recovery and quality of life, integrating objective metrics would provide a more comprehensive understanding of surgical efficacy. Future prospective studies should aim to include both subjective and objective data points to further validate these findings and elucidate the physiological correlations of patient-centered outcomes.
Finally, another potential limitation of our study is the reliance on subjective patient-reported outcomes (PROs) to assess sleep improvement, without incorporating objective measures such as the frequency of nocturnal awakenings, actigraphy, or validated sleep quality indices. While these objective assessments could offer more quantifiable data, it is important to emphasize that patient-reported experiences remain the cornerstone of evaluating symptom relief and quality of life, especially in chronic conditions like carpal tunnel syndrome. The growing emphasis on PROs in healthcare highlights that the patient’s perception of improvement is ultimately the most meaningful indicator of surgical success. Nonetheless, future studies should aim to complement subjective assessments with objective sleep metrics to provide a more comprehensive understanding of postoperative recovery.
Conclusion
Long-term follow-up of patients who underwent open carpal tunnel release surgery revealed that individuals with severe carpal tunnel syndrome, in comparison to patients with mild and moderate disease, experienced a statistically significant longer time to full recovery, lower self-reported pain relief, decreased satisfaction, reduced functionality improvement, and less improvement in activities of daily living (ADLs). However, they exhibited better improvement in sleep quality.
Acknowledgements
We acknowledge the cooperation of the IT office to facilitate the collection of data from electronic and archived files.
Author contributions
The authors made the following contributions to the study: Moh’d S. Dawod conceptualized the study, developed the methodology, wrote the original draft, and supervised the project. Mohammad N. Alswerki handled data curation, performed formal analysis, and reviewed and edited the manuscript. Ahmad F. Alelaumi conducted investigation, managed resources, and created visualizations. Israa Alasfoor contributed to validation and project administration. Omar F. Alelaumi assisted with methodology and data curation, and reviewed and edited the manuscript. Abdulaziz Aldoseri performed formal analysis, created visualizations, and reviewed and edited the manuscript. Shahad W. Khalid wrote the original draft and managed resources. Ali M. Sharadga handled data curation and formal analysis, and reviewed and edited the manuscript. Joud M. Sharadga contributed to validation and investigation. Hamzeh M. Alsamarah managed resources, data curation, and visualizations. Fatimah Alshadeedi oversaw project administration, conducted investigation, and reviewed and edited the manuscript. Aws Khanfar was involved in conceptualization and project administration.
Funding
All authors received NO financial support for the preparation, research, authorship, and publication of this manuscript.
Data availability
The data that support the findings of this study are available upon appropriate request from the corresponding author. The data is not publicly available due to privacy or ethical restrictions.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available upon appropriate request from the corresponding author. The data is not publicly available due to privacy or ethical restrictions.