Carpal tunnel syndrome (CTS) and cubital tunnel syndrome (CBTS) are the 2 most common peripheral compression neuropathies.1–3 Both conditions are frequently bilateral and often coexist.4–7 Simultaneous bilateral carpal tunnel releases (CTRs) and, recently, simultaneous bilateral cubital tunnel releases (CBTRs) have shown promising results with improved cost-effectiveness, decreased recovery time, decreased total time off work, and similar satisfaction rates when compared with staged releases,7–13 whereas unilateral simultaneous CTRs and CBTRs are routinely performed, simultaneous bilateral CTRs and CBTRs (quadruple release) have not been reported. The purpose of this study was to describe the authors' experience with quadruple release. The hypothesis was that quadruple tunnel release (QTR) is satisfactory and allows early return to unrestricted use.
Materials and Methods
Following institutional review board approval, all patients undergoing simultaneous bilateral CTRs and CBTRs performed between January 2010 and March 2014 were retrospectively reviewed. The sample represented all the patients who had this procedure at the time institutional review board approval was granted. Inclusion criteria were adult patients 18 years or older who had primary CTR as well as primary CBTR on both upper extremities during the same visit to the operating room. Exclusion criteria included a prior release of any of the tunnels and the performance of other concomitant procedures. Patients were identified based on Current Procedural Terminology codes. All CTRs were performed in the same-day operative suite using a 2-portal endoscopic carpal tunnel system (ECTRA II; Smith & Nephew, Andover, Massachusetts), and all CBTRs were in situ releases, with anterior subcutaneous transposition only if the ulnar nerve subluxed from the groove intraoperatively. Two of the study patients received anterior subcutaneous transpositions for this reason. The patients were asked to keep their postoperative dressing on full-time for 3 days; they were allowed to use their arms within tolerance with no specific restrictions effective immediately, and no changes were made in the postoperative protocol for the 2 patients with transposition. All patients were followed up at 2 weeks for wound checks, and then monthly afterward until they were released to full use. A postoperative questionnaire was administered by phone regarding satisfaction with the procedures, willingness to make the same choice in retrospect, and the time needed to return to full, unrestricted use. An independent party not involved with the care of the patients conducted the questionnaire administration and data entry. Questionnaires were conducted following release from the care of the primary surgeon, which ranged from 4 to 18 months postoperatively.
Satisfaction was rated using the following scale: highly satisfied, satisfied, neutral, and highly dissatisfied. Willingness to make the same choice was rated as a yes/no question. Return to work was determined based on the patient's report. Descriptive statistics were analyzed by a statistician.
Thirty patients underwent QTR during the study period and were contacted to complete the questionnaire. Nine were males and 21 were females. Twenty-four patients responded to the questions; 23 (95.8%) were satisfied or highly satisfied with the outcomes, and 1 was not satisfied. Twenty-three (95.8%) patients would choose to undergo QTR in retrospect. The time to return to unrestricted use was 27 days on average, with 1 patient returning to work over 3 months postoperatively. Excluding the outlier, the average time to return to unrestricted use was 20.4 days. Five patients were not able to be reached after 5 phone call attempts, and 1 patient refused to participate. There were no surgical complications, including no infections, no dehiscence, and no iatrogenic injuries. The recovery time and satisfaction for the 2 transposition patients were not different from the in situ CBTR patients.
The prevalence of CTS has been reported to be between 3% to 8%,1–3 and the prevalence of CBTS has been reported to be between 1.8% to 5.9%.3 Up to 70% of CTS patients present with bilateral symptoms,4 and up to 91% of unilateral CTS develop contralateral CTS at a later time.4–6 Ipsilateral CTS may be present in as many as 55% of CBTS patients.7 Simultaneous unilateral CTR and CBTR has been reported in 38% to 44%.7,13
Studies have shown that simultaneous bilateral CTR improves cost-effectiveness, lessens recovery time and total time off work, and has similar satisfaction rates.8–12 Simultaneous bilateral CBTR has shown promising results as well.7,13
Quadruple tunnel release (ie, simultaneous bilateral CTR and CBTR) has not been described in the literature. The authors have found that QTR is effective and well tolerated and shortens postoperative recovery compared with staged releases. The majority of patients in this study were either satisfied or highly satisfied, and their willingness to make the same choice in the future was high as well. The time to return to unrestricted use was short, averaging 3 to 4 weeks.
Bilateral simultaneous CTR is well tolerated by patients compared with staged releases.9,14–16 The current authors' experience with simultaneous bilateral CTR and CBTR has been positive. Still, many surgeons are reluctant to suggest bilateral simultaneous procedures due to concern for postoperative morbidity regarding personal care and return to work.14 The current authors initially offered the “all 4 at once” procedure to high-risk patients, with the goal of decreasing their exposure to anesthesia. The earliest patients included those on dialysis and with multiple other comorbidities. The authors noticed how well they tolerated QTR, which led them to expand it to healthy patients who prefer earlier return to unrestricted use. To date, the authors have performed more than 100 QTRs. Initially, they were hesitant to offer QTRs to all comers, but the experience with the first 3 patients in this study was so positive that they began to routinely offer it as an option to all patients with nerve compression at all 4 sites. The authors allow patients to self-select; no one is excluded except patients with previous surgery at those sites.
Health care costs, both direct and indirect, are affected by the choice to undergo staged vs simultaneous releases. Direct medical costs include physician, anesthesia, and facility fees.8,9,15,17,18 Typically, “bilateral surgery” accrues 50% payment adjustments for physician and facility fees, and each additional procedure gets additional adjustment. Anesthesia fees are directly related to anesthesia time, which may be less for simultaneous releases than the combined total time of staged procedures.17 Indirect costs include lost time from work, income, and productivity. As health care costs continue to rise, it is becoming increasingly important to optimize the allocation of finite medical resources.
There were limitations to this study. It was retrospective in nature, not randomized, and susceptible to recall bias. The authors, enthusiastic about the benefits this approach offers, may have potentially biased the patients' choices and experiences during recovery. The authors were not involved with administration of the questionnaire and data collection. Although QTR intuitively seems like it would lead to substantial cost savings, the current study was not designed to assess the economic impact.
This study demonstrates that QTRs are technically feasible and well tolerated by patients. Combining bilateral CTR and CBTR into one surgery has the potential to reduce total recovery time and expedite return to unrestricted use. This approach may save money for patients and health insurance payers.
- Dale AM, Harris-Adamson C, Rempel D, et al. Prevalence and incidence of carpal tunnel syndrome in US working populations: pooled analysis of six prospective studies. Scand J Work Environ Health. 2013;39(5):495–505. doi:10.5271/sjweh.3351 [CrossRef] PMID:23423472
- Atroshi I, Englund M, Turkiewicz A, Tägil M, Petersson IF. Incidence of physician-diagnosed carpal tunnel syndrome in the general population. Arch Intern Med. 2011;171(10):943–944. doi:10.1001/archinternmed.2011.203 [CrossRef] PMID:21606100
- An TW, Evanoff BA, Boyer MI, Osei DA. The prevalence of cubital tunnel syndrome: a cross-sectional study in a U.S. metropolitan cohort. J Bone Joint Surg Am. 2017;99(5):408–416. doi:10.2106/JBJS.15.01162 [CrossRef] PMID:28244912
- Bagatur AE, Zorer G. The carpal tunnel syndrome is a bilateral disorder. J Bone Joint Surg Br. 2001;83(5):655–658. doi:10.1302/0301-620X.83B5.0830655 [CrossRef] PMID:11476299
- Padua L, Padua R, Nazzaro M, Tonali P. Incidence of bilateral symptoms in carpal tunnel syndrome. J Hand Surg Br. 1998;23(5):603–606. doi:10.1016/S0266-7681(98)80010-7 [CrossRef] PMID:9821602
- Goyal V, Bhatia M, Padma MV, Jain S, Maheshwari MC. Electrophysiological evaluation of 140 hands with carpal tunnel syndrome. J Assoc Physicians India. 2001;49(5):1070–1073. doi:10.1016/s0266-7681(98)80010-7 [CrossRef] PMID:11868858
- Cross D, Matullo KS. Concomitant endoscopic carpal and cubital tunnel release: safety and efficacy. Hand (N Y).2014;9(1):43–47. doi:10.1007/s11552-013-9552-3 [CrossRef] PMID:24570636
- Elfar JC, Foad MB, Foad SL, Stern PJ. A cost analysis of staged and simultaneous bilateral carpal tunnel release. Hand (N Y).2012;7(3):327–332. doi:10.1007/s11552-012-9436-y [CrossRef] PMID:23997743
- Fehringer EV, Tiedeman JJ, Dobler K, McCarthy JA. Bilateral endoscopic carpal tunnel releases: simultaneous versus staged operative intervention. Arthroscopy. 2002;18(3):316–321. doi:10.1053/jars.2002.30643 [CrossRef] PMID:11877620
- Pagnanelli DM, Barrer SJ. Bilateral carpal tunnel release at one operation: report of 228 patients. Neurosurgery. 1992;31(6):1030–1033. doi:10.1227/00006123-199212000-00007 [CrossRef] PMID:1335136
- Vimercati L, Lorusso A, L'abbate N, Assennato G. Bilateral carpal tunnel syndrome and ulnar neuropathy at the elbow in a pizza chef. BMJ Case Rep. 2009;2009:bcr11.2008.1293. doi:10.1136/bcr.11.2008.1293 [CrossRef] PMID:21686375
- Wang AA, Hutchinson DT, Vanderhooft JE. Bilateral simultaneous open carpal tunnel release: a prospective study of postoperative activities of daily living and patient satisfaction. J Hand Surg Am. 2003;28(5):845–848. doi:10.1016/S0363-5023(03)00257-0 [CrossRef] PMID:14507517
- Seradge H, Owen W. Cubital tunnel release with medial epicondylectomy factors influencing the outcome. J Hand Surg Am. 1998;23(3):483–491. doi:10.1016/S0363-5023(05)80466-6 [CrossRef] PMID:9620189
- Weber RA, Boyer KM. Consecutive versus simultaneous bilateral carpal tunnel release. Ann Plast Surg. 2005;54(1):15–19. doi:10.1097/01.sap.0000139566.23908.2c [CrossRef] PMID:15613876
- Nesbitt KS, Innis PC, Dubin NH, Wilgis EFS. Staged versus simultaneous bilateral endoscopic carpal tunnel release: an outcome study. Plast Reconstr Surg. 2006;118(1):139–145. doi:10.1097/01.prs.0000221073.99662.39 [CrossRef] PMID:16816686
- Osei DA, Calfee RP, Stepan JG, Boyer MI, Goldfarb CA, Gelberman RH. Simultaneous bilateral or unilateral carpal tunnel release? A prospective cohort study of early outcomes and limitations. J Bone Joint Surg Am. 2014;96(11):889–896. doi:10.2106/JBJS.M.00822 [CrossRef] PMID:24897736
- Park KW, Boyer MI, Gelberman RH, Calfee RP, Stepan JG, Osei DA. Simultaneous bilateral versus staged bilateral carpal tunnel release: a cost-effectiveness analysis. J Am Acad Orthop Surg. 2016;24(11):796–804. doi:10.5435/JAAOS-D-15-00620 [CrossRef] PMID:27668663
- Huracek J, Heising T, Wanner M, Troeger H. Recovery after carpal tunnel syndrome operation: the influence of the opposite hand, if operated on in the same session. Arch Orthop Trauma Surg. 2001;121(7):368–370. doi:10.1007/s004020100260 [CrossRef] PMID:11510899