Surgery for Carpal Tunnel Syndrome in Patients with Chronic Pain
Can a person who suffers from chronic neck, back, or leg pain have a successful surgery for carpal tunnel syndrome? This is the question addressed by hand surgeons from the Department of Plastic and Reconstructive Surgery at The Johns Hopkins University. They compared the results of surgical treatment between two groups of patients who had a carpal tunnel release.

Chronic pain was defined by pain lasting more than three months. The two groups included one (chronic pain) group who had taken narcotic pain medications for pain in some other part of the body besides the hand/wrist. The second (control) group had carpal tunnel syndrome but without chronic pain and without taking pain medications.

Everyone was evaluated before and after surgery for pain, hand/wrist function, and satisfaction with treatment. Follow-up occurred at regular intervals after surgery for a full year. Despite the surgeons' concern that chronic pain patients would not recover well after carpal tunnel surgery, there were no differences between the two groups at the end of the study.

That may sound like the surgeons pre-judge patients just because they report chronic pain. But research does show that people who are in chronic pain process pain messages differently from people who don't have daily pain. And many physicians have treated patients who don't seem to want to get better or who don't seem to respond to anything except narcotic medications.

There are other concerns as well. For example, it is difficult to accurately evaluate and diagnose patients who are in chronic pain. Performing carpal tunnel surgery on someone who doesn't have a true carpal tunnel syndrome could lead to poor outcomes. It's difficult to know when a patient is magnifying symptoms or even making up the problem for the attention. Typically, such patients don't respond to treatment no matter what approach is taken.

But as this study clearly showed, patients who have surgery for carpal tunnel syndrome (CTS) who also have chronic (nonhand) pain elsewhere in the body do quite well. In fact, they do just as well as patients having CTS surgery who don't have chronic pain and who aren't taking narcotic pain meds.

The authors say that despite concerns about poor coping skills, drug-seeking behaviors, addiction to narcotics, or mental illness among chronic pain patients, this group of patients should not be denied surgical treatment for hand/wrist pain from carpal tunnel syndrome (CTS).

There is no evidence to support the idea that they won't benefit from the same treatment offered to patients with CTS who don't have chronic pain and who aren't taking narcotics. And as this study showed, the benefit of pain relief and return of hand function outweighs the possible risks of further drug addiction.

They do suggest some strategies for pain management among chronic pain patients having carpal tunnel surgery. First, only the primary care physician (or pain specialist) should be in charge of prescribing and supervising pain meds for chronic pain patients. The surgeon will give the necessary pain meds the day of the surgery and the day after surgery. But after that, any further medications must be under the care and coordination of the primary/pain physician. The overall plan should be discussed with all concerned including the patient, surgeon, primary care physician, and pain specialist if one is involved.
Keith E. Follmar, MD, et al. Outcome of Endoscopic Carpal Tunnel Release in Patients with Chronic Nonhand Pain Compared with Those Without Chronic Pain. In The Journal of Hand Surgery. August 2012. Vol. 37A. No. 8. Pp. 1585-1590.