Carpal tunnel release (CTR) is one of the most common upper-extremity procedures, with excellent outcomes and lasting benefits. When comparing the surgical options of open versus endoscopic CTR, studies have noted higher rates of transient nerve injury but lower risk of wound problems after endoscopic release. Long-term clinical outcomes appear to be similar between the 2 techniques.
What about the associated costs? This is a multidimensional question of particular relevance given the high economic impact of carpal tunnel syndrome, a leading cause of lost work time. Barnes et al. shed new light on the cost-effectiveness of endoscopic versus open CTR in a recent JBJS report, offering a look from societal and payer perspectives. In this cost-effectiveness analysis, the authors developed a Markov model to evaluate unilateral open versus endoscopic CTR in an office setting with local anesthesia and an operating room (OR) setting under monitored anesthesia care. Comprehensive outcomes data from published meta-analyses helped to inform the modeling, while the costs of CTR, performed from 2012 to 2016, were obtained from a large Medicare claims database.
The authors note that, with complications rates being relatively balanced between the 2 techniques, and differences in quality-adjusted life-years being small (<1 quality-adjusted life-day), “procedural and lost-productivity costs primarily drove the results.” (The model assumed 8.21 fewer days of missed work after endoscopic CTR.) Health-care costs are larger for endoscopic CTR, but “the impact of lost productivity was important.” For instance, endoscopic release in the OR setting becomes cost-effective if the patient’s expected return to work is even 1.2 days earlier than that following open CTR in the OR. However, because of the lower costs of performing open CTR in the office setting, endoscopic CTR in the OR is cost-effective only if the expected return to work is at least 3.9 days earlier than that following open CTR in the office.
Overall, the authors concluded that, from a payer perspective, endoscopic CTR is more expensive than open CTR and only becomes truly cost-effective if performed in an office setting under local anesthesia. However, from a societal perspective, earlier return to work may help tip the scales in favor of endoscopic release. The authors caution that additional research is needed to confirm their findings based on the latest surgical techniques and return-to-work protocols.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Click here for a JBJS Clinical Summary on the treatment of carpal tunnel syndrome.
I had done open carpal tunnel releases for 32 years. When I needed my own carpal tunnel releases, I had both done endoscopically under local anesthetic in our surgery center by my partner on a Friday afternoon after work. I returned to work on Monday morning per usual doing clinic for three days then had a full OR day doing total joints on Thursday. I know I could not have done that had I had open procedures. After that experience, I quit doing carpal tunnel releases unless one of my patients wanted it done open, which was rare.
Michael, I switched from “mini open” carpal tunnel release (1-2xm incision in the palm releasing the TCL retrograde using a tome or blade guide) to Agee single portal eCTR back in 2009. What struck me most was those patients on whom I had done mini-open on one side and eCTR on the other— they uniformly hands-down preferred eCTR. Now of course an anecdote like this is not true evidence, but it sure highlights what you are saying. In particular I recall a friend I did eCTR for on a Wednesday and he was using the operated hand to flip burgers on the grill by Saturday. Another triathlete who was riding a spin bike leaning on the operated hand 3 days postop. An electrician who was using the hand for light activity the day after surgery at work. A landscaper who was riding the stand-up mower using the operated hand on the hand controls 2 days postop. The anecdotes abound…
The difference in postop discomfort and recovery time comparing eCTR vs oCTR is remarkable.
https://txosa.com/carpal-tunnel-syndrome/
Endoscopic carpal tunnel release: a minimally invasive release of the carpal tunnel ligament performed with an endoscopy camera the size of a small pen, inserted through a small incision at the wrist crease.
Open carpal tunnel release: a classic surgical release with an incision made in the palm over the carpal tunnel ligament.