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Commentary on Bolster et al. Cubital tunnel syndrome: a comparison of an endoscopic technique with a minimal invasive open technique

This article was needed. Hand surgeons are trained to use endoscopes for wrist and elbow arthroscopy and are naturally keen to use endoscopic techniques for procedures such as carpal tunnel release and ulnar nerve decompression at the elbow. The logical expectations include smaller scars (hopefully leading to more rapid rehabilitation and return to work/ activities of daily living), equivalent or better symptom relief than open surgical procedures, and happier patients. This study shows that such expectations may not always be correct. The most notable finding, which may surprise many surgeons, is that there is no significant difference in the length of the skin incision; but also important is no difference in the functional outcome on a disease-specific scoring system or in patient satisfaction. While the author comments that numbers are small (partly owing to loss to follow-up), our own findings with a minimally invasive technique (Karthik et al., 2012) in patients with severe (Dellon score 3) symptoms confirm that good symptom relief and patient satisfaction is to be expected and an endoscopic technique may be unnecessary. Some larger series of endoscopic releases have reported complications. The most extensive endoscopic procedure appears to be that described in detail by Hoffmann and Siemionow (2006), which includes stretching the soft tissues around the nerve distally and proximally prior to endoscopic viewing. In the reported series of 75 releases they had one case of CRPS type 1 with a poor long term outcome and nine patients with hypo-aesthesia in the territory of the ulnar antebrachial cutaneous nerve; all but one resolved within 3 months. Yoshida et al. (2009) reported a much gentler technique, under local anaesthetic and without tourniquet. They used the McGowan grading of severity and out of the 35 procedures reported, had 18 severe cases before operation and four at one year after operation (an improvement rate of 78% – it is not possible from the published data to know the extent of improvement in the severe cases). Interestingly they claim that post-operative daily activities were unrestricted and return to work was earlier (but there is no control group for comparison to justify this – the present article could indicate that this comment is ‘wishful thinking’). Readers will make their own conclusions, but with the published evidence at present available, my personal feeling is that it is tempting to advise the well recognized American ‘kiss’ principle – keep it simple stupid!