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.