The American Academy of Orthopaedic Surgeons
Evidence-based Practice (EBP) standards are in a state of continuous evolution. Current EBP standards demand that physicians use the best available evidence to guide their clinical decision making processes. Increasingly rigorous EBP standards have also resulted in more rigorous clinical studies of ever stronger design, complexity, and statistical analysis. This clinical practice guideline consists of a systematic review of the available literature regarding the treatment of carpal tunnel syndrome. The purpose of this clinical practice guideline is to help improve carpal tunnel syndrome treatment based on the current best evidence. The systematic review detailed herein was conducted between June and October of 2007 and demonstrates where there is good evidence, where evidence is lacking, and what topics future research must target in order to improve carpal tunnel syndrome treatment. The AAOS Carpal Tunnel Syndrome (CTS) Guideline Work Group systematically reviewed the available literature, evaluated the level of evidence found in that literature, and subsequently wrote the following recommendations based on a rigorous, standardized process.
Goals and Rationale
The AAOS has created this clinical practice guideline to improve patient care by outlining the appropriate information-gathering and decision-making processes involved in managing the treatment of carpal tunnel syndrome. This guideline is also an educational tool to guide qualified physicians (see Intended Users) through a series of treatment decisions in an effort to improve the quality and efficiency of care. This guideline should not be construed as including all proper methods of care or excluding methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment must be made in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. Further, the patient must be an active participant in treatment decisions. All treatment for CTS is based on the assumption that final decisions are predicated on patient and physician mutual communication about available treatment alternatives and procedures applicable to the individual patient. These decisions include an evaluation of the patient’s current quality of life with CTS. Patients will present with considerable variability in acceptable choices, needs, and access to non-operative alternatives. It is understood that after the patient has been informed of available alternative non-operative therapies and has discussed these options with their physician, the informed patient choice may be to go directly to surgery.
Scope and Organization
This guideline is intended to be used by all appropriately trained surgeons and all qualified phsicians considering treamtemtn of CTS. Typically, appropriately trained surgeons will have completed medical training, a qualified residency and some may have additional sub-specialty training. Insurance payers, govermental bodies, and health-policy decision-makers may also find this guideline useful as an evolving standard of evidence regarding treament of Carpal Tunnel Syndrome.
Persons of all genders, races, ages, occupations and health status may be afflicted by Carpal Tunnel Syndrome. The present guideline is aimed towards treatment of carpal tunnel syndrome in adults (defined as patients older than 18 years of age).
These recommendations assume that the patient has reversible mechanical compression of the median nerve based on the diagnostic criteria set forth in the AAOS clinical practice guideline for The Diagnosis of Carpal Tunnel Syndrome. This does not include patients who have nerve damage characterized by irreversible microscopic damage to the nerve ultra-structure. Such cases, understood to exist, without biopsy evidence, have a worse prognosis for recovery with sustained numbness, tingling, paralysis, dyshidrotic changes of the skin, and pain. Diagnostic stratification studies which define preoperative criteria for this division between reversible and irreversible damage were not found. The clinical objective in the more damaged group has lesser expectations and anticipated outcomes by definition.
Incidence and Prevalence
Carpal tunnel syndrome incidence in the United States has been estimated at 1-3 cases per 1000 persons per year. Prevalence is approximately 50 cases per 1000 persons in the general population.
Burden of Disease
Many Americans experience symptoms of carpal tunnel syndrome and they also expect relief of the condition, which can be accomplished with proper treatment. Untreated or ill-treated carpal tunnel syndrome may worsen and progress to permanent sensory loss and thenar paralysis in some cases.
As carpal tunnel syndrome in the workplace demands attention and as the number of worker’s compensation cases are filed increases, the expense for lost productivity and cost of treatment continues to increase. According to the National Institute of Health (NIH), the average lifetime cost of carpal tunnel syndrome, including medical bills and lost time from work, is estimated to be about $30,000 for each injured worker.” Hanrahan et al quote similar estimates by the National Council on Compensation Insurance that estimates the average CTS case costs $29,000 in Worker’s Compensation benefits and medical costs. The Bureau of Labor Statistics reports, as of 2005, the major industry division with highest number of events and exposures is manufacturing. There were more than 3.8 million visits made to physicians in office-based practices in 2003 because of carpal tunnel syndrome.6 According to the Burden of Musculoskeletal Diseases in the United States (2008, p.136), the National Health Interview Survey “is believed to underreport the incidence of injuries” and the Bureau of Labor Statistics only report work related data.
Carpal Tunnel Syndrome (CTS) is among the most common disorders of the upper extremity. It is related to many factors but is thought to be caused by increased pressure on the median nerve in the carpal tunnel at the wrist.
Diagnosis and Treatment
Diagnosis of carpal tunnel syndrome is made on the basis of signs, symptoms, and electro-diagnostic tests, as put forth by the AAOS clinical practice guideline on Diagnosis of Carpal Tunnel Syndrome. Appropriate diagnosis is a critical factor to providing treatment.
Treatment for CTS is based on the assumption that final decisions are predicated on patient and physician mutual communication, discussion of available treatment alternatives and procedures applicable to the individual patient. Once the patient has been informed of available alternative non-operative therapies and has discussed these options with his/her physician, an informed decision can be made. Clinician input based on experience with both conservative management and surgical skills increases the probability of identifying patients who will benefit from specific treatment options. Patient compliance with prescribed treatments is also a contributing factor for successful treatment.
Several key co-morbidities and/or human factors potentially increase the risk of developing carpal tunnel syndrome. Primary considerations include advancing age, female gender, and the presence of diabetes and/or obesity. Other risk factors include pregnancy, specific occupations, cumulative and repetitive motion injuries, strong family history, specific medical disorders such as hypothyroidism, autoimmune diseases, rheumatologic diseases, arthritis, renal disease, trauma, anatomic predisposition in the wrist and hand due to shape and size, infectious diseases, and substance abuse. These are all common exclusion criteria in CTS treatment studies and hence these potential risks have not been clearly assessed.
Persons involved in manual labor in some occupations have a greater incidence and severity of the symptoms. The relationship between work, co-morbidities and personal factors require good physician judgment, experience with medical evidence and knowledge of the vast occupational literature in assigning and apportioning causation. In many cases, there is no identifiable co-morbidity or causal relationship.
Source: The American Academy of Orthopaedic Surgeons