Abstract
Purpose
To evaluate whether commonly obtained preoperative diagnostic findings are associated with early clinically meaningful improvement in patient-reported outcomes after carpal tunnel release (CTR) and to assess the durability of any observed associations across early postoperative follow-up.
Methods
This retrospective cohort study included patients who underwent CTR between 2012 and 2020 and completed standardized preoperative evaluation with carpal tunnel syndrome-6 scoring, ultrasound, and electrodiagnostic testing, along with Boston Carpal Tunnel Questionnaire assessments before surgery and at 2 and/or 6 weeks after surgery. Clinically meaningful improvement was defined using established minimal clinically important difference (MCID) thresholds for the Symptom Severity Scale and Functional Status Scale. Associations among preoperative diagnostic findings, demographic variables, and postoperative outcomes were evaluated using univariate, exploratory multivariable, and longitudinal generalized estimating equation analyses.
Results
Ninety-nine patients were included. Boston Carpal Tunnel Questionnaire symptom and function scores improved at all postoperative timepoints, with more than half of patients achieving MCID by 6 weeks. At 2 weeks, abnormal sensory nerve action potential amplitude was associated with smaller functional improvement, whereas select demographic factors were associated with MCID achievement. At 6 weeks, prolonged distal sensory latency and distal motor latency were associated with higher odds of achieving Symptom Severity Scale MCID, and prolonged distal sensory latency was associated with greater symptom and functional score reductions. However, associations varied by outcome domain and timepoint, and no variable demonstrated a consistent longitudinal association with clinically meaningful improvement.
Conclusions
Early recovery after CTR is characterized by substantial symptomatic and functional improvement but marked interpatient variability. Although select preoperative diagnostic and demographic factors demonstrated time-limited associations with early outcomes, when treated as cutoff values, no variable being abnormal reliably predicted clinically meaningful improvement in this cohort across early follow-up. These findings support the use of preoperative diagnostic testing cutoff thresholds primarily for diagnostic confirmation and clinical decision-making rather than for prognosticating early postoperative recovery.
Type of study/level of evidence
Prognostic IV.
Key words: Boston Carpal Tunnel Questionnaire, Carpal tunnel syndrome, Electrodiagnostic testing, Minimal clinically important difference, Prognostic factors
Carpal tunnel syndrome (CTS) is the most common peripheral compressive neuropathy, affecting an estimated 1% to 5% of the population.1,2 Carpal tunnel release (CTR) is the standard surgical treatment, yet postoperative outcomes vary substantially; although many patients achieve complete symptom resolution, others continue to experience persistent or recurrent symptoms.3 Multiple preoperative diagnostic tools, each widely used in clinical practice, exist to aid in diagnosing CTS. The CTS-6 clinical scoring system integrates symptom characteristics and physical examination findings.4 Ultrasound provides cross-sectional area (CSA) measurements of the median nerve to evaluate nerve swelling, and electrodiagnostic testing, including distal sensory latency (DSL), distal motor latency (DML), sensory nerve action potential (SNAP), and compound muscle action potential (CMAP), quantifies the degree and nature of nerve conduction impairment.5 These modalities are well validated for diagnostic use; however, evidence regarding their prognostic utility for predicting postoperative functional recovery remains limited.6
Postoperative outcomes are commonly assessed using the Boston Carpal Tunnel Questionnaire (BCTQ), which includes the Symptom Severity Scale (SSS) and Functional Status Scale (FSS). In addition to absolute score reductions, thresholds for minimal clinically important difference (MCID) provide a patient-centered benchmark for meaningful improvement. One validated method defines MCID as a reduction of ≥0.46 × baseline SSS and ≥0.28 × baseline FSS, thereby scaling the threshold to individual preoperative severity.7,8 This approach acknowledges that patients with more severe baseline symptoms require a larger absolute improvement to perceive meaningful benefit.
Although CTS-6, ultrasound, and electrodiagnostic tests have been extensively studied for diagnostic purposes, few investigations have examined their ability to predict clinically notable postoperative improvement. This gap limits clinicians’ prognostic ability to provide individualized counseling based on preoperative findings. Therefore, the aim of this study was to evaluate whether preoperative diagnostic test results predict short-term postoperative outcomes as measured by BCTQ scores and MCID achievement. We hypothesized that abnormal preoperative test results would be associated with higher odds of achieving clinically meaningful improvement at early postoperative time points.
Materials and Methods
Study cohort
A retrospective cohort analysis was performed of patients who underwent CTR for clinically diagnosed CTS at a single tertiary academic center between 2012 and 2020. Patients were identified from a prospectively maintained institutional database in which patients underwent standardized preoperative evaluation, including CTS-6 clinical scoring, ultrasound assessment of median nerve CSA, electrodiagnostic testing, and baseline BCTQ assessment.
Patients were included if they completed preoperative diagnostic testing and had at least 1 postoperative BCTQ assessment at 2 and/or 6 weeks. Patients were excluded if they underwent revision CTR, had prior ipsilateral wrist surgery, were missing required preoperative diagnostic data, or had no postoperative outcome data. This study was approved by the University of Pittsburgh Institutional Review Board (STUDY20070308) with waiver of informed consent and Health Insurance Portability and Accountability Act authorization. The investigation was conducted in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines.
Preoperative diagnostic assessments
Preoperative evaluation incorporated clinical, imaging, and electrodiagnostic testing. Carpal tunnel syndrome-6 scores of 12 or greater were considered abnormal. Ultrasound was used to measure median nerve CSA at the carpal tunnel inlet, with values of 10 mm2 or greater classified as abnormal. Electrodiagnostic testing included assessment of DML, DSL, SNAP, and CMAP; however, not all electrodiagnostic parameters were available for every patient. Abnormal thresholds were defined as DML ≥4.0 ms, DSL ≥3.5 ms, SNAP amplitude ≤6.0 μV, and CMAP amplitude ≤10.0 μV.
Outcomes
Outcomes were derived from the BCTQ, including the SSS and FSS, collected before surgery and at 2 and 6 weeks after surgery. Longer-term follow-up was not analyzed because of substantial attrition.
Postoperative improvement was evaluated using 2 complementary outcome definitions. Clinically meaningful improvement was assessed using established MCID thresholds scaled to baseline severity (≥0.46 × baseline SSS and ≥0.28 × baseline FSS) as described by Deekleermaker, where they suggest that values for MCID derived from baseline SSS or FSS scores are more accurate than a fixed cutoff value for MCID.7 Continuous change in SSS and FSS scores from baseline was analyzed as a secondary outcome to characterize the magnitude and direction of early postoperative symptom and functional improvement.
Statistical analysis
Patient demographics, including sex as documented in the electronic medical records, baseline characteristics, and diagnostic findings were summarized using descriptive statistics. Continuous variables were reported as means with standard deviations (SDs) and categorical variables as counts with percentages. All preoperative diagnostic tests, including electrodiagnostic parameters, ultrasound CSA, and CTS-6 score, were analyzed as dichotomous clinical variables categorized as normal or abnormal based on predefined clinical cutoff thresholds, and analyses evaluating diagnostic severity as continuous predictors were not performed. Minimal clinically important difference achievement was considered the primary outcome, whereas continuous score reduction was analyzed as a secondary outcome to contextualize improvement magnitude given the baseline severity–dependent nature of MCID thresholds.
Associations between baseline variables and postoperative outcomes were evaluated using regression-based methods. Univariate logistic regression was used for MCID outcomes and univariate linear regression for continuous score changes, with results reported as odds ratios or regression coefficients with 95% CIs.
Exploratory multivariable analyses were performed using forward stepwise selection (P = 0.05), incorporating preoperative diagnostic measures and demographic covariates. Given the limited sample size and correlation among variables, these models were considered exploratory and not intended to establish predictive models.
Longitudinal associations across 2 and 6-week follow-up were evaluated using generalized estimating equations with an exchangeable working correlation structure to account for within-patient correlation of repeated postoperative measurements. These models allowed the inclusion of patients with observations at 1 or more postoperative timepoints. All statistical tests were 2-tailed, and statistical significance was defined as P < .05.
Results
Demographic data
A total of 680 patients were evaluated before surgery for CTS within a prospectively maintained institutional database. Among these, 288 patients underwent CTR and had at least 1 documented postoperative follow-up visit. Application of predefined eligibility criteria, including complete preoperative diagnostic testing and at least 1 postoperative BCTQ assessment at 2 and/or 6 weeks, yielded 148 patients with diagnostic data and a final analytic cohort of 99 patients. Clinical exclusions, including revision CTR and prior ipsilateral wrist surgery, were applied as defined in the methods section (Table 1). The mean age was 54.6 years, 71% of patients were women, and the mean body mass index was 33.9 kg/m2. Mean baseline BCTQ scores were 3.14 for the SSS and 2.63 for the FSS.
Table 1.
Baseline Patient Characteristics (N = 99)
| Characteristic | Value |
|---|---|
| Age, mean (SD), y | 54.6 (13.8) |
| Female, n (%) | 70 (71%) |
| BMI, mean (SD), kg/m2 | 33.9 (7.9) |
| White ethnicity, n (%) | 74 (75%) |
| Diabetes mellitus, n (%) | 28 (28%) |
| Baseline BCTQ SSS, mean (SD) | 3.14 (0.76) |
| Baseline BCTQ FSS, mean (SD) | 2.63 (0.92) |
BCTQ, Boston Carpal Tunnel Questionnaire; FSS, Functional Status Scale; SSS, Symptom Severity Scale.
Continuous variables are presented as mean (SD). Categorical variables are presented as n (%).
BCTQ score reductions and MCID achievement
Postoperative BCTQ data were available for 78 patients (79%) at 2 weeks and 49 patients (49%) at 6 weeks (Table 2). Forty-two of 78 patients (54%) achieved MCID derived from baseline scores for SSS, and 37 of 77 patients (48%) achieved MCID for FSS. At 6 weeks, MCID was achieved by 28 of 49 patients (57%) for SSS and 30 of 49 patients (61%) for FSS. Mean SSS reduction was 1.43 ± 0.89 at 2 weeks and increased to 1.60 ± 0.86 at 6 weeks. Mean FSS reduction was 0.58 ± 1.38 at 2 weeks and 1.08 ± 1.08 at 6 weeks.
Table 2.
Postoperative Improvements in MCID for BCTQ Scores
| Time Point | SSS Reduction, Mean (SD) | FSS Reduction, Mean (SD) | SSS MCID Achieved, % | FSS MCID Achieved, % |
|---|---|---|---|---|
| 2 wks | 1.43 (0.89), n = 78 | 0.58 (1.38), n = 77 | 42 (54%) | 37 (48%) |
| 6 wks | 1.60 (0.86), n = 49 | 1.08 (1.08), n = 49 | 28 (57%) | 30 (61%) |
BCTQ, Boston Carpal Tunnel Questionnaire; FSS, Functional Status Scale; MCID, minimal clinically important difference; SSS, Symptom Severity Scale.
Continuous outcomes are presented as mean (SD). Categorical outcomes are presented as n (%). Sample sizes reflect available data at each postoperative timepoint.
Associations at 2 weeks
At the 2-week follow-up, male sex was significantly associated with achievement of MCID for SSS, whereas increasing age was associated with achievement of MCID for FSS (Table 3). No electrodiagnostic or ultrasound variables were associated with MCID attainment at this timepoint.
Table 3.
Univariate Associations With Postoperative Outcomes at 2 Weeks
| Variable | Outcome | Effect Size (95% CI) | P Value |
|---|---|---|---|
| Male | SSS MCID | OR = 0.23 (0.07–0.67) | .009 |
| Male | SSS score reduction | Β = −0.46 (−0.91 to −0.02) | .041 |
| Age (per y) | FSS MCID | OR = 0.96 (0.92–0.99) | .019 |
| SNAP abnormal | FSS score reduction | Β = −1.2 (−2.2 to −0.17) | .023 |
FSS, Functional Status Scale; MCID, minimal clinically important difference; OR, odds ratio; SNAP, sensory nerve action potential; SSS, Symptom Severity Scale; β, regression coefficient.
Univariable associations were evaluated using logistic regression for MCID outcomes and linear regression for continuous BCTQ score reductions. Only variables with at least 1 significant 2-week association are shown.
When analyzed as continuous outcomes, male sex was associated with a greater reduction in SSS scores, whereas abnormal SNAP amplitude was associated with smaller reductions in FSS scores at 2 weeks (Table 3).
Associations at 6 weeks
At the 6-week follow-up, achievement of MCID for SSS was significantly associated with higher BMI, prolonged DML, and prolonged DSL (Table 4). No demographic, clinical, or diagnostic variables were notably associated with MCID achievement for FSS at this time point.
Table 4.
Univariate Associations With Postoperative Outcomes at 6 Weeks
| Variable | Outcome | Effect Size (95% CI) | P Value |
|---|---|---|---|
| DSL abnormal | SSS MCID | OR = 5.33 (1.13–31.0) | .043 |
| DML abnormal | SSS MCID | OR = 4.80 (1.23–21.6) | .029 |
| BMI | SSS MCID | OR = 1.08 (1.01–1.17) | .046 |
| DSL abnormal | SSS score reduction | β = 0.65 (0.06–1.3) | .032 |
| DSL abnormal | FSS score reduction | β = 0.92 (0.17–1.7) | .019 |
| Diabetes mellitus | SSS score reduction | β = 0.77 (0.23–1.3) | .006 |
| BMI | SSS score reduction | β = 0.03 (0.00–0.06) | .025 |
DML, distal motor latency; DSL, distal sensory latency; FSS, Functional Status Scale; MCID, minimal clinically important difference; OR, odds ratio; SSS, Symptom Severity Scale; β, regression coefficient.
Univariable associations were evaluated using logistic regression for MCID outcomes and linear regression for continuous BCTQ score reductions. Only variables with at least 1 significant 2-week association are shown.
When analyzed as continuous outcomes, a greater reduction in SSS scores at 6 weeks was associated with prolonged DSL, higher body mass index, and the presence of diabetes mellitus. A greater reduction in FSS scores was associated only with prolonged DSL (Table 4).
Multivariable and longitudinal analyses
Exploratory multivariable analyses were performed using forward stepwise selection to evaluate combinations of preoperative diagnostic and demographic variables associated with MCID achievement (Table 5). Across models, individual variables were retained for specific outcome definitions and follow-up timepoints; however, the retained variables differed by outcome domain and timepoint, and no variable or combination of variables was consistently retained across models.
Table 5.
Exploratory Multivariable Associations With MCID Achievement
| Outcome | Variable | Adjusted OR | 95% CI | P Value |
|---|---|---|---|---|
| 2-wk SSS MCID | Male | 0.23 | 0.07–0.67 | .009 |
| 6-wk SSS MCID | DML abnormal | 5.01 | 1.12–27.4 | .043 |
| BMI (per kg/m2) | 1.11 | 1.02–1.23 | .024 | |
| 2-wk FSS MCID | Age (per y) | 0.96 | 0.92–0.99 | .019 |
| 6-wk FSS MCID | DSL abnormal | 4.25 | 0.91–22.3 | .071 |
DML, distal motor latency; DSL, distal sensory latency; FSS, Functional Status Scale; MCID, minimal clinically important difference; OR, odds ratio; SSS, Symptom Severity Scale.
Models generated using forward stepwise logistic regression; variables shown represent those retained in final exploratory models.
P-values in bold indicate significance (P < .05).
In longitudinal generalized estimating equation analyses incorporating both 2- and 6-week follow-up, no preoperative diagnostic or demographic variable demonstrated a statistically significant association with MCID achievement for either SSS or FSS (Table 6).
Table 6.
Longitudinal GEE Associations With MCID Achievement Across Early Follow-Up
| Outcome | Predictor | Adjusted OR | 95% CI | P Value |
|---|---|---|---|---|
| SSS MCID (2 + 6 wks) | CTS-6 abnormal | 0.96 | 0.39–2.36 | .92 |
| CSA abnormal | 0.94 | 0.37–2.43 | .91 | |
| DML abnormal | 1.12 | 0.43–2.94 | .82 | |
| CMAP abnormal | 1.03 | 0.45–2.39 | .94 | |
| DSL abnormal | 1.30 | 0.46–3.65 | .61 | |
| SNAP abnormal | 0.37 | 0.10–1.37 | .14 | |
| FSS MCID (2 + 6 wks) | CTS-6 abnormal | 1.78 | 0.73–4.30 | .22 |
| CSA abnormal | 1.58 | 0.64–3.87 | .34 | |
| DML abnormal | 1.15 | 0.45–2.92 | .77 | |
| CMAP abnormal | 1.16 | 0.52–2.59 | .73 | |
| DSL abnormal | 1.16 | 0.42–3.22 | .78 | |
| SNAP abnormal | 0.42 | 0.12–1.45 | .18 |
Longitudinal associations were evaluated using generalized estimating equation (GEE) logistic regression models with an exchangeable working correlation structure, incorporating both 2- and 6-week postoperative assessments.
CMAP, compound muscle action potential; CSA, cross-sectional area; DML, distal motor latency; DSL, distal sensory latency; FSS, Functional Status Scale; MCID, minimal clinically important difference; OR, odds ratio; SNAP, sensory nerve action potential; SSS, Symptom Severity Scale.
Discussion
Carpal tunnel release results in substantial early symptomatic and functional improvement, yet recovery trajectories vary across patients. In this study, we evaluated whether commonly obtained preoperative diagnostic findings and patient characteristics are associated with early clinically meaningful improvement after CTR, using both MCID attainment and raw changes in BCTQ symptom and function scores. Preoperative diagnostic variables were analyzed using clinically defined abnormal versus normal cutoff thresholds rather than continuous measures of diagnostic severity. Although several baseline variables demonstrated statistically significant associations with early postoperative outcomes, these relationships were time-limited and domain-specific. No preoperative diagnostic or demographic variable demonstrated a consistent longitudinal association with clinically meaningful improvement across early follow-up in this limited cohort with mixed follow-up timing.
Prognostic value of electrodiagnostic testing
Electrodiagnostic findings demonstrated time-dependent associations with early postoperative recovery. At 2 weeks, abnormal SNAP amplitude was associated with smaller improvements in functional status, suggesting delayed early functional recovery in patients with sensory axonal involvement. However, this association was confined to a single functional outcome, did not extend to symptom severity or MCID attainment, and did not persist at later follow-up.
In contrast, electrodiagnostic parameters were more frequently associated with outcomes at 6 weeks, particularly for symptom-based measures. Prolonged DSL and DML were each associated with higher odds of achieving symptom-based MCID, and prolonged DSL was also associated with greater reductions in both symptom and functional scores. Similar findings have been reported in select cohorts, including Dennerlein et al, who observed greater symptom improvement among patients with longer distal motor and sensory latencies.9 Other studies have suggested that reduced sensory amplitudes may be associated with slower or less complete recovery.10
Despite these observations, electrodiagnostic measures did not demonstrate consistent longitudinal relationships with postoperative improvement. The broader literature has generally failed to demonstrate reproducible prognostic associations between preoperative nerve conduction abnormalities and postoperative patient-reported outcomes after CTR.11,12 Collectively, these results suggest that electrodiagnostic measures may capture aspects of disease severity or recovery timing, but when treated as a diagnostic cutoff, do not provide reliable prognostic discrimination for clinically meaningful postoperative improvement.
Ultrasound and clinical diagnostic measures
Preoperative ultrasound findings did not demonstrate consistent associations with either MCID attainment or the magnitude of early postoperative improvement. This aligns with prior work showing that median nerve CSA is valuable for diagnostic confirmation but does not reliably predict postoperative symptoms or functional recovery.13 Similarly, CTS-6 clinical scores were not associated with early postoperative outcomes in adjusted or longitudinal analyses. Given the conceptual overlap between CTS-6 and BCTQ symptom constructs, CTS-6 may provide limited incremental prognostic information in this context.
Demographics
Demographic variables demonstrated limited, time-dependent associations with early postoperative recovery. At 2 weeks, male sex was associated with lower odds of achieving symptom-based MCID and smaller SSS reductions. This finding was confined to symptom outcomes, was not observed at 6 weeks or longitudinally, and contrasts with much of the existing literature, raising the possibility of residual confounding or baseline severity effects.14, 15, 16
Increasing age was associated with lower odds of achieving FSS MCID at 2 weeks, consistent with prior work suggesting slower early recovery among older patients.14,17,18 However, this association was not observed at 6 weeks or longitudinally, suggesting age may influence early recovery tempo rather than overall benefit.
At 6 weeks, higher BMI was associated with symptom-based MCID achievement and greater SSS reduction, whereas diabetes mellitus was associated with greater SSS reduction only. Prior studies evaluating obesity and diabetes as prognostic factors after CTR have reported mixed findings, and associations in the present cohort were symptom-specific and time-limited.15,16,19
Socioeconomic factors and access to care may influence disease severity at presentation and postoperative outcomes. Prior studies have shown that socioeconomically disadvantaged patients often present with more advanced disease and worse baseline and postoperative patient-reported outcomes, potentially reflecting delays in diagnosis, referral, or treatment.20, 21, 22 The present study was not designed to evaluate socioeconomic or insurance-related disparities, as these variables were not consistently available. Future studies incorporating standardized measures of socioeconomic status and access to care may better contextualize postoperative recovery.
Clinical implications
Preoperative clinical, ultrasound, and electrodiagnostic testing remain essential for confirming the diagnosis and characterizing disease severity in CTS. However, their utility for predicting early clinically meaningful improvement after CTR appears limited. Although several baseline diagnostic variables demonstrated statistically significant associations with early postoperative outcomes, these relationships were inconsistent across outcome domains and follow-up timepoints, and no variable demonstrated a consistent longitudinal association with clinically meaningful improvement. This pattern mirrors prior literature reporting mixed and largely nonreproducible prognostic associations between preoperative diagnostic findings and postoperative patient-reported outcomes after CTR.16,23,24 Clinically, these findings support the use of preoperative diagnostic tests primarily for diagnostic confirmation and surgical decision-making rather than for forecasting early postoperative improvement. Prognostic counseling should emphasize the high likelihood of symptomatic benefit following CTR while acknowledging interpatient variability in early recovery.
Limitations
This study has several limitations. High attrition at later follow-up intervals limited statistical power for longitudinal analyses and reduced precision for detecting modest associations. As a retrospective analysis, no a priori power calculation was performed, and nonsignificant findings should be interpreted cautiously.
Several electrodiagnostic associations were accompanied by wide CIs, reflecting limited precision related to sample size and event frequency; these findings should be interpreted as exploratory. The single-center design may limit generalizability, and multivariable analyses employing forward stepwise selection are sensitive to sample size and correlated predictors.
An additional limitation relates to the dichotomization of preoperative diagnostic variables using clinically defined cutoff thresholds. This approach emphasizes diagnostic classification rather than the degree of abnormality and may obscure associations between diagnostic severity and postoperative recovery. In particular, the CTS-6 threshold functions as a clinical indicator rather than a strict diagnostic boundary. Analyses evaluating diagnostic severity gradients were not performed.
Differential follow-up patterns may also introduce selection bias. Although a 2-week follow-up is standard after CTR, a 6-week follow-up is often performed on an as-needed basis; patients returning at 6 weeks may represent nonrandom subsets. Finally, socioeconomic status and insurance coverage could not be adequately assessed because of inconsistent documentation, limiting the evaluation of access-related disparities.
Conflicts of Interest
Dr Fowler serves as the Editor-in-Chief of Journal of Hand Surgery Global Online and is a paid consultant for Integra LifeSciences, but had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Dr Giladi. No benefits in any form have been received or will be received by the other authors related directly to this article.
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