February 7, 2008
Getting Patients Back to Work After Carpal Tunnel Surgery
By Newey, Martyn Clarke, Malcolm
KEYWORDS Carpal tunnel syndrome / Nurse-led service / Return to work This article describes the condition known as carpal tunnel syndrome and reviews a carpal tunnel service that was started in Leicester in 1999. We look at how the service has developed to meet patient needs, and how we now aim to return patients back to function and employment as quickly as possible after surgery.Introduction
Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment disorder. The condition is characterised by pain, pins and needles, numbness and weakness in the affected hand and is caused by compression of the median nerve within the carpal tunnel. In the United Kingdom the incidence of CTS is between 43 and 74 per 100,000 per year (Burke 2000), and there are approximately 50,000 carpal tunnel procedures performed each year (The Information Centre 2007).
The carpal tunnel is produced by the small carpal bones of the wrist, which form an arch (Figure 1). The flexor retinaculum or transverse carpal ligament forms the roof of the canal through which the median nerve and the long flexor tendons pass. The carpal tunnel is fairly narrow and stiff and anything that produces pressure on or within the canal will affect the traversing structures and in particular the median nerve.
In the majority of cases the cause of CTS is unknown. It is more common in females and in people aged in their 40s and 50s. It can occur in pregnancy and typically resolves afterwards. CTS also occurs in patients with hypothyroidism, diabetes or who are obese, or in individuals who either sustain injuries to their wrist or hand or who have arthritis of their hands. Certain occupational activities have been associated with CTS and there are a number of rare diseases that can cause deposition of abnormal substances in and around the carpal tunnel, leading to nerve irritation. These diseases include sarcoidosis, amyloidosis, leukaemia and multiple myeloma.
Figure 1 Cross-section of the carpal tunnel
It is important to identify and treat any underlying conditions such as hypothyroidism as symptoms of CTS may then resolve. Non- surgical treatments include wrist splints, stretching exercises and modification of hand activity. Nonsteroidal anti-inflammatory drugs such as ibuprofen may help to reduce swelling and thus relieve pain. Steroid injection into the carpal tunnel may offer temporary benefit. Other treatments that have been studied include acupuncture, ultrasound, yoga and vitamin B6. The standard surgical procedure involves dividing the transverse carpal ligament thus relieving pressure on the median nerve. This can be carried out through a standard or small longitudinal palmar incision or performed endoscopically.
Traditional view of carpal tunnel surgery
Carpal tunnel decompression is a good operation with a good outcome and low complication rate. The majority of carpal tunnel decompressions are done as day cases and can be done under local or general anaesthetic. A tourniquet is usually recommended to provide a bloodless field.
Following surgery the hand is usually bandaged or even splinted. Splinting has been recommended to avoid complications of palmar bowstringing of flexor tendons, wound dehiscence and entrapment of the median nerve within the surgical incision. A survey of American hand surgeons (Duncan et al 1987) found that 81% splinted patients' wrists for two to four weeks following carpal tunnel surgery. A postal survey of hand surgeons in and around the Trent and the East Midlands region suggested that splinting was used for one to three weeks following open, and one to two weeks following endoscopic carpal tunnel decompression.
Return to work after carpal tunnel surgery may depend on a number of factors, and may vary with gender, occupation, age and presence of postoperative pain. In a recent study, the average time off work following surgery for CTS was 28 days in both open and endoscopic carpal tunnel surgery (Atroshi et al 2006).
A patient-driven service
In 1999, a review of our service found that patients waiting for carpal tunnel surgery accounted for 10% of patients on our waiting lists. Furthermore, we identified large numbers of patients who were not only waiting considerable lengths of time for treatment, but also for assessment and investigation. To address this problem we therefore developed a carpal-tunnel service as a nurse-led service, and this has now been running for several years.
Over the years the service has changed through developments that have been primarily patient-driven. An important aspect of the service was ensuring that patients were at ease with their treatment. This involved removing barriers that were centred round a fear of the surgical pathway. The more we looked at the pathway the more we became aware that even apparent straight-forward aspects of the process we as a healthcare professionals took for granted, could be quite distressing for patients under our care. The main issues included the fear of being anywhere near a hospital, having to go on a ward, having to get changed out of normal clothes, removing make- up and jewellery and having to fast, especially for patients who were diabetic. The thought of going to an operating theatre, lying on a table surrounded by people they did not know, possibly having to have a general anaesthetic, all added to a fear factor. Therefore, surgery was taken out of the traditional place of the theatre. Patients did not need to wear gowns and did not need to lie down on an operating table to have their surgery. One of the more unpleasant aspects of carpal tunnel surgery is the discomfort from the tourniquet. We therefore performed surgery without a tourniquet.
As the service developed it also became apparent that patients had concerns about the length of time they would need to have off work following surgery. A large proportion of our patients are not salaried and therefore 'not working' meant 'no income'. We therefore started to encourage early return to function through immediate exercise.
Patients are now assessed in clinic, operated upon and then reviewed postoperatively by the same nurse practitioner. We use a dedicated room separate from both main and day case theatres, and surgery is performed under local anaesthetic without a tourniquet.
The patient pathway
It is essential to obtain a full history and perform an appropriate examination in patients who are referred with a diagnosis of carpal tunnel syndrome. This will allow the identification of any underlying condition or other problem such as cervical radiculopathy.
There is occasionally a role for further investigations such as blood tests and Xrays. Nerve conduction studies can be helpful and it is now possible to perform these at the same time as the initial clinical assessment with a portable device (Figure 2). This saves the patient having to make an extra visit to hospital and also avoids the considerable waiting times that can occur for traditional nerve conduction studies.
Once a diagnosis of CTS has been established, treatment options can be discussed. Non-operative treatments can be pursued where appropriate such as when symptoms are mild. Surgery is indicated when previous non-operative options have failed and symptoms are becoming more severe and interfering with sleep and daily activities. Patients are able to book a date and time for their surgery that suits them.
The GMC has established several fundamental principles on consent and these covered in the publication Protecting Patients, Guiding Doctors - seeking Patients' Consent: The Ethical Considerations (GMC 1998). This document states that an individual obtaining consent must be 'suitably trained and qualified ... have sufficient knowledge of the proposed treatment and ... understand the risks involved' (GMC 1998). Consequently during the early development of the service, consent was obtained by a medical practitioner. As our nurse-operator became more experienced, and as part of the training process, he gradually played a greater role until eventually he had sufficient experience to be able to obtain consent without assistance.
Patients are able to arrive a few minutes before their surgery, which is performed in a dedicated room separate from main and day case theatres. Patients do not have to change out of their ordinary clothes or wear a gown, and are able to relax in a comfortable chair. They can also be accompanied by relatives or friends while their operation is being performed (Figure 3).
1. A longitudinal palmar incision is used and initially, the area around the intended incision is infiltrated with 6-7ml of 0.25% Bupivicaine mixed with 1 in 200,000 adrenaline. The patient is then prepped and draped. Once the effects of the local anaesthetic are confirmed an incision is made and a small self-retaining retractor is inserted. (Figure 4).
Figure 8 One minute postoperatively
2. The transverse carpal ligament, which is deep to the longitudinal fibres of the superficial palmar aponeurosis, is divided and the underlying median nerve identified. As division of the transverse carpal ligament proceeds the median nerve, which because of the compression is initially quite pale, begins to blush (Figure 5).
3. The decompression is carried distally to the fat pad in which lies the deep palmar arch. A Macdonald's probe can be inserted proximally and rotated to ensure a complete proximal release has also been performed (Figure 6). 4.The skin edges are then sutured with interrupted 4/0 nylon (Figure 7).
5. The wound is covered with a light mepore dressing and the patient is encouraged to start exercising their hand immediately (Figure 8). They are also encouraged to return to their normal function and employment as quickly as they want to.
Patients are reviewed two weeks following surgery when the sutures are removed. Advice about using the hand normally is usually reinforced and at this stage most patients can be discharged.
The service we developed offered a number of advantages. This was a single practitioner led-service and our nurse operator became very experienced. Waiting times were cut significantly and patient satisfaction was high. A report on the initial pilot study of the service (Newey et al 2006) showed improvement in 98.7% of patients with a complication rate of 2.5%. In particular, there were no adverse events associated with not using a tourniquet. There are also certain patients in whom the use of a tourniquet would be contraindicated (Figure 9). We did not see an increase in infection rates as a result of surgery being taken out of a recognised and more traditional operating environment. Our nurse-operator now performs over 750 cases a year, which obviously frees up valuable time in both day-case and main theatres.
Figure 9 A patient on renal dialysis with a vascular fistula
As the service developed and our new way of delivery of care was refined, we noticed that there was a change in the mindset and attitude of patients being treated, who became much more relaxed and happier. We continue to encourage relatives and patients under our care to be forthright with their feelings on the way they have been treated by our service and we also encourage suggestions for helping to make the service more about being a pleasant experience, than just a visit for treatment.
The service we have developed avoids the expense of a conventional operating facility or even a day case bed, and there are clearly therefore savings related to this (Newey 2007). Furthermore, because our postoperative management encourages early movement, it is possible for individuals to regain function quite soon following surgery. In a recent study of a further 494 patients in our service, there were 318 (64%) patients in employment, of whom 191 were manual workers, 81 were non-manual workers and 46 were in secretarial work. Overall, 93% of all those in employment had returned to work by two weeks from surgery. The Confederation of British Industry report a cost of Pounds 76.70 for each day an employee is off work due to sickness (CBI 2007). An individual who is able to return to work even one week earlier than previously would have been expected, following carpal tunnel surgery, to theoretically produce a saving to the economy of Pounds 383. The 318 patients in our study could have therefore produced a potential economic saving of Pounds 121,794. Given that nationally there are about 50,000 carpal tunnel procedures carried out each year, then the potential savings are significant.
Carpal tunnel syndrome is the most common peripheral nerve entrapment disorder and about 50,000 carpal tunnel decompressions are performed each year. We have developed a carpal tunnel service that has taken the surgical treatment out of the usual theatre environment. In doing so, we have shown that a high quality service in terms of good outcomes and low complication rates - can be achieved with an excellent level of patient satisfaction. To a certain extent, the service has challenged conventional concepts about where, how and by whom surgical procedures can be performed, and many of these developments have been patient-driven.
In removing these relatively straightforward cases from the usual theatre environment, valuable time is created for the more complex procedures that do need to be done in a conventional operating theatre. Although this approach may be applicable in other areas, there will clearly be local issues in terms of clinical needs and senior support, as well as risk management and clinical governance issues that will need to be addressed. However, we have shown that with the right enthusiasm and support, it is possible to provide a good quality surgical service for a defined group of patients within an equally well-defined clinical setting.
We would like to acknowledge Val Younger and the Medical Illustration Department of the University Hospitals of Leicester NHS Trust for their help in preparing Figure 1.
Return to work after carpal tunnel surgery may depend on a number of factors, and may vary with gender, occupation, age and presence of postoperative pain
Carpal tunnel syndrome is the most common peripheral nerve entrapment disorder
Atroshi I, Larsson G, Omstein E, Hofer M, Johnsson R, Ranstam J 2006 Outcomes of endoscopic surgery compared with open surgeiy for carpal tunnel syndrome among employed patients: randomised controlled trial British Medical Journal 332 (7556) 1473-1476
Burke FD 2000 Carpal tunnel syndrome: reconciling 'demand management' with clinical need The Journal of Hand Surgery (Br) 25 (2) 121-127
Confederation of British Industry 2007 Attending to absence. Absence and labour turnover survey 2007 London, CBI
Duncan KH, Lewis RC, Foreman KA, et al 1987 Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: results of a questionnaire The Journal of Hand Surgery (Am) 12 384-391
General Medical Council 1998 Protecting Patients, Guiding Doctors - seeking Patients' Consent The Ethical Considerations Available from: www.mc-uk.org/guidance/current/library/consentasp [Accessed 6 December 2007]
The Information Centre 2007 Hospital Episode Statistics [Online] Available from: www.hesonline.org. uk/ease/servlet/ ContentServer?sitelD=1937&categoryl D=210 [Accessed 6 December 2007]
Newey M, Clarke M, Green T et al 2006 Nurse-led management of carpal tunnel syndrome: an audit of outcomes and impact on waiting times Annals of the Royal College of Surgeons of England 88 (4) 399- 401
Newey M 2007 (Untitled letter) Annals of the Royal College of Surgeons of England 89 (1) 89-90
About the authors
Copyright Association for Perioperative Practice Feb 2008
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