Abstract
Purpose: The utility of electrodiagnostic tests (EDx) for patients with a high pretest probability of idiopathic median neuropathy at the carpal tunnel (IMNCT) based on characteristic symptoms and signs is debated. Decision-making and care strategies could be informed by a better understanding of factors associated with surgeon recommendations for electrodiagnostic testing. Methods: Ninety-one upper-extremity surgeons participated in an online, survey-based experiment. Participants viewed 7 vignettes of patients with carpal tunnel syndrome, with the following factors randomized in each vignette: patient age, gender, magnitude of incapability, symptom intensity and the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results. We sought patient and surgeon factors associated with ordering EDx and surgeon-rated comfort with performing carpal tunnel release (CTR) without EDx. Results: Surgeons recommended EDx for over half of the patient vignettes, with notable variation (median, 57%; interquartile range, 14–100), and felt relatively neutral, on average, offering CTR without EDx. Twenty-six (29%) out of 91 surgeons ordered EDx for all patient scenarios, and 18 surgeons (20%) did not order testing for any scenario. A lower likelihood of EDx was associated with older age and positive provocative tests results. Greater surgeon comfort offering CTR without EDx was associated with older patients, the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results. Conclusions: Upper-extremity surgeons are neutral regarding diagnosing IMNCT based on electrodiagnostic evidence of pathology and are relatively more comfortable offering surgery without EDx in older patients that present with key aspects of carpal tunnel syndrome. There is notable variation in care, with half of all surgeons always or never ordering EDx. Clinical relevance: Future studies can investigate whether a treatment strategy offering surgery to patients with a high pretest probability of IMNCT and only using EDx in intermediate probability scenarios can limit use of testing without affecting patient health.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 736-744 |
| Number of pages | 9 |
| Journal | Journal of Hand Surgery |
| Volume | 47 |
| Issue number | 8 |
| DOIs | |
| State | Published - Aug 2022 |
Funding
The Science of Variation Group members are Julie E. Adams, MD, Lars E. Adolfsson, MD, Thomas Apard, MD, Duffield Ashmead, MD, L. Christopher Bainbridge, MD, Hugh Brent Bamberger, MD, Taizoon Baxamusa, MD, Luis A. Buendia, MD, Kenneth Butters, MD, Juan Carlos Cagnone, MD, Maurizio Calcagni, MD, Guilherme Carpeggiani, MD, Chritopher E. Casstevens, MD, Kevin Chivers, MD, Ramon de Bedout, MD, C. Liam Dwyer, MD, John M. Erickson, MD, Kent Erol, MD, Peter J. Evans, MD, Daniel Falcon, Sebastian Farr, MD, Carlos Henrique Fernandes, MD, Thomas J. Fischer, MD, Richard S. Gilbert, MD, Jacob D. Gire, MD, Angela Ylenia Giuffrida, MD, Taco Gosens, MD, Michael W. Grafe, MD, Robert R.L. Gray, MD, Jeffrey A. Greenberg, MD, Thierry G. Guitton, MD, Warren C. Hammert, MD, Bernard F. Hearon, MD, Steven L. Henry, MD, Eric P. Hofmeister, MD, Jerry I. Huang, MD, Eric F. Ibrahim, MD, Peter Jebson, MD, Sanjeev Kakar, MD, F. Thomas D. Kaplan, MD, Stephen A. Kennedy, MD, Jason H. Ko, MD, Steven Kronlage, MD, Kenneth E. Lee, MD, Alexander M. Marcus, MD, John A. McAuliffe, MD, Stephen Mitchell, MD, Constanza Lucia Moreno-Serrano, MD, Michael P. Nancollas, MD, David C. Napoli, MD, James F. Nappi, MD, Luis Felipe Naquira Escobar, MD, Betsy M. Nolan, MD, Jose A. Ortiz II, MD, Paolo Paladini, MD, Bradley A. Palmer, MD, Michael Jason Palmer, MD, Nata Parnes, MD, Juan Martin Patiño, MD, D. Paul Patterson, MD, George Pianka, MD, Miguel A. Pirela Cruz, MD, Andreas Platz, MD, Daniel Polatsch, MD, Mark Richardson, MD, David Ruch, MD, Kevin M. Rumball, MD, Julie B. Samora, MD, Ellen S. Satteson, MD, Evan D. Schumer, MD, Adam B. Shafritz, MD, Todd Siff, MD, Prasad Sitaram, MD, J. Sebastiaan Souer, Anne Spaans, MD, Benjamin Sutker, MD, Jay Talsania, MD, Jason D. Tavakolian, MD, Andrew L. Terrono, MD, Marco van der Pluijm, MD, Roger van Riet, MD, Ali J. Vochteloo, MD, Ryan P. Walbeehm, MD, Christopher J. Walsh, MD, Lawrence Weiss, MD, W. Jaap Willems, MD, Brian P.D. Wills, MD, Jeffrey Wint, MD, Megan M. Wood, MD, Charalampos Zalavras, MD, and David W. Zeltser, MD. Dr Ring received royalties from Wright Medical for elbow plates in the amount of less than USD $10,000 per year and from Skeletal Dynamics for an internal joint stabilizer elbow in the amount of between $10,000 and $100,000 USD per year; is a Deputy Editor for Hand and Wrist, the Journal of Orthopaedic Trauma, and Clinical Orthopaedics and Related Research and has received or may receive payments or benefits in the amount of USD $5,000 per year; and received honoraria from meetings of the AO North America, AO International, and various hospitals and universities.
Keywords
- CTS-6
- Carpal tunnel syndrome
- electrodiagnostic testing
- neurodiagnostic testing
- neuropathy
ASJC Scopus subject areas
- Surgery
- Orthopedics and Sports Medicine