Purpose
Our study aimed to evaluate the relationship between electrodiagnostic study (EDS) severity and utilization of treatments for carpal tunnel syndrome (CTS) as well as the duration of time between EDS and carpal tunnel release (CTR).
Methods
We conducted a retrospective medical chart review at a single tertiary hand center to evaluate CTS-related care that patients received after EDS. We recorded patient age, sex, race/ethnicity, insurance type, CTS-related surgical and nonsurgical healthcare utilization after EDS testing, and number of days between EDS and CTR.
Results
Among all patients with an eventual diagnosis of CTS who received EDS (n = 210), nearly half had normal or mild severity (23%, n = 48; and 28%, n = 58, respectively) and the other half had moderate or severe EDS findings (26%, n = 55; and 23%, n = 49, respectively). Patients with severe findings had the highest rate of receiving surgery (53%) compared with patients with mild and moderate findings (33% vs 46%, respectively). Among the patients who received CTR (n = 73), patients with severe EDS findings had the shortest time to CTR (59.5 days; interquartile range [IQR], 30–81), compared with mild severity (170 days; IQR, 87–415) and moderate severity (77 day; IQR, 42–292). Moderate and severe EDS findings were associated with significantly higher odds of receiving CTR in adjusted analyses (odds ratio, 2.48, 95% confidence interval, 1.04–5.93 and odds ratio 3.79, 95% confidence interval, 1.51–9.50, respectively) compared with patients with mild EDS findings. However, the odds of receiving steroid injection and hand therapy/orthosis were not significantly different based on severity.
Conclusions
Electrodiagnostic study severity had a direct relationship to the probability of receiving surgery but did not correlate with use of nonsurgical treatment. The study findings signal a need to evaluate the value of nonsurgical treatments in patients with severe EDS findings.
Type of study/level of evidence
Prognostic II.
Key words
Electrodiagnostic studies (EDS) have been advocated by some to determine the severity of nerve compression in patients with carpal tunnel syndrome (CTS),
1
,2
in particular for patients being considered for carpal tunnel release (CTR).3
Historically, a substantial number of surgeons have reported the practice of routinely requesting EDS prior to surgical evaluation and intervention.4
, 5
, 6
, 7
However, given that CTS is widely regarded as a clinical diagnosis and EDS is not a reference standard test, routine utilization of EDS as a confirmatory test prior to CTR may unnecessarily increase cost and delay surgery in patients who receive little or no value from the testing.8
The appropriateness of grading the severity of CTS based on electrodiagnostic findings is debated.
9
, 10
, 11
, 12
, 13
, 14
, 15
The 2016 American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPG) on the management of carpal tunnel syndrome supports using either EDS and/or diagnosis questionnaires to aid in the diagnosis of CTS, with the guideline no longer recommending that the test be used routinely in all patients being considered for surgery, as was recommended in the past.16
Given that clinical and electrophysiological severity often are not correlated,American Academy of Orthopaedic Surgeons
Management of Carpal Tunnel Syndrome Evidenced-Based Clinical Practice Guideline.
Management of Carpal Tunnel Syndrome Evidenced-Based Clinical Practice Guideline.
www.aaos.org/ctsguideline
Date accessed: August 23, 2018
15
,17
the utility of using EDS severity to guide treatment is unclear.14
Furthermore, studies have shown conflicting results between EDS severity and post-CTR outcomes.17
, 18
, 19
, 20
, 21
, 22
, 23
, 24
, 25
, 26
, 27
, 28
, 29
Data are lacking to understand the impact of EDS severity on influencing treatment plans and timing of surgical treatment. Thus, we sought to evaluate the relationship between EDS severity and posttesting treatment recommendations for patients with CTS. Specifically, we aimed to evaluate CTS-related health care utilization after EDS to evaluate the impact of severity on utilization of surgical and nonsurgical treatments, as well as time to surgery in patients ultimately undergoing CTR. We hypothesized that patients with moderate and severe CTS by EDS criteria would have similar utilization of surgical and nonsurgical treatments and time to surgery after EDS testing for CTS.
Materials and Methods
Study cohort
The study received approval by the institutional review board. We conducted a retrospective medical record review to evaluate CTS-related care that patients received before and after EDS testing at a single academic hand center. An institutional administrative database, including a combination of data used for billing and electronic medical record purposes, was screened to identify patients with an International Classifications Diagnosis Code, 9th Edition Code (ICD-9) for CTS (code 354.0). We included patients aged 18 years and older with a coded diagnosis of CTS who received primary care at the institution, underwent EDS between January 1, 2013 and December 31, 2014, and had physician evaluation and management for CTS on medical record review. Patients were required to be established with a primary care provider in the health system or have been referred internally to more reliably capture the totality of their CTS-related care. The end date for study inclusion was chosen to include a time period in which only ICD-9 coding was used for uniformity of the cohort selection process, given potential changes in provider coding practices during the transition from ICD-9 to ICD-10. Patients were excluded if they were not observed for at least 12 months before and after the EDS encounter to ensure established care from an internal provider and to have sufficient time to observe relevant CTS-related health care utilization. The inclusion criteria did not require referral to a hand surgeon during the post-EDS observation period.
Study variables
The administrative database and medical records of the selected patients were reviewed to record patient characteristics including age, sex, race/ethnicity, and insurance type (private insurance, Medicare, Medicaid, governmental insurance, and workers’ compensation). Based on the final EDS report, the severity of CTS was categorized into 1 of 4 groups: normal, mild, moderate, and severe using the American Association of Neuromuscular and Electrodiagnostic Medicine criteria.
30
Patients classified into the normal severity group did not have CTS by EDS criteria, but had a coded diagnosis of CTS elsewhere in the medical record. The CTS-related health care utilization before and after EDS was recorded, which included whether patients received diagnostic testing (magnetic resonance imaging, ultrasound, EDS, computed tomography, or x-ray), CTR, steroid injection, hand therapy (HT), or orthosis wear recommendation within 12 months before or after the EDS encounter during the inclusion period. We also recorded the time duration between EDS and CTR (days) for patients who received surgery.Data analysis
We calculated descriptive statistics to compare the frequency of various CTS-related treatments recommended after testing based on EDS severity, including utilization of additional diagnostic tests, steroid injection, HT and/or orthoses, and surgery. The use of HT and/or recommendation of orthosis use was combined into a single treatment category for data analysis because patients often receive orthoses during an HT encounter for CTS, in addition to other routes (eg. direct purchase, supply in clinic). Use of one treatment did not preclude the use of another type of treatment. Thus, in the analyses, use of treatments relative to EDS severity were evaluated individually. The chi-square test was used to identify differences in utilization of post-EDS treatments across severity groups. We used the Kruskal-Wallis equality-of-population rank test to assess the association between severity and median wait time between EDS and CTR in patients receiving surgery. Median wait time was chosen as the summary statistic, as opposed to the mean, to represent the typical patient experience and minimize the influence of patients at the far extremes, given that the distribution of wait times was non-normal. We used multivariable logistic regression models to evaluate the association between the use of specific post-EDS treatments and the severity of CTS by EDS criteria. For the multivariable analysis, we evaluated receipt of CTR, steroid injection, and recommendation of HT/orthosis in the post-EDS period as the outcome for each logistic regression model, while adjusting for patient characteristics and severity. Statistical significance was defined as P less than .05.
Results
The study cohort included 210 CTS patients who received EDS and met the inclusion criteria. Of these patients, 148 (71%) were female, 165 (79%) were Caucasian, and 120 (57%) had private insurance. The mean age was 59 years (SD, 13 years). Table 1 describes the patient characteristics and insurance type.
Table 1Patient Characteristics
| Patient Variable | n | % |
|---|---|---|
| Entire cohort | 210 | |
| Age (mean, SD) | 58.9 | 13 |
| Sex | ||
| Female | 148 | 71 |
| Male | 62 | 30 |
| Race/ethnicity | ||
| Caucasian | 165 | 79 |
| African American | 25 | 12 |
| Hispanic or Latino | 12 | 6 |
| Asian | 4 | 2 |
| American Indian | 1 | 0.5 |
| Other | 2 | 1.0 |
| Unspecified | 1 | 0.5 |
| Insurance type | ||
| Private Insurance | 120 | 57 |
| Medicare | 38 | 18 |
| Medicaid | 26 | 12 |
| Governmental insurance | 13 | 6 |
| Workers’ compensation | 4 | 2 |
| Unspecified | 9 | 4 |
∗ Frequencies may not add up to 100 within subgroups owing to rounding.
Among the study cohort who underwent EDS during the observation period, nearly half had normal or mild EDS severity (23%, n = 48; and 28%, n = 58, respectively) and the other half had moderate or severe EDS findings (26%, n = 55; and 23%, n = 49, respectively). The frequency of undergoing CTR after EDS evaluation increased with the severity. Among the range of severity, 53% of patients with severe EDS findings received surgery, followed by 46% of moderate, 33% of mild, and 6% of normal EDS severity patients (P < .05) (Table 2).
Table 2Posttesting CTS Treatments based on Electrodiagnostic Severity
| CTS Test or Treatment | Electrodiagnostic Severity, n (%) | Total (n) | P | |||
|---|---|---|---|---|---|---|
| Normal | Mild | Moderate | Severe | |||
| Total | 48 (23) | 58 (28) | 55 (26) | 49 (23) | 210 | |
| Additional testing | ||||||
| Yes | 6 (13) | 9 (16) | 5 (9) | 5 (10) | 25 | .7 |
| No | 42 (88) | 49 (85) | 50 (91) | 44 (90) | 185 | |
| CTR | ||||||
| Yes | 3 (6) | 19 (33) | 25 (46) | 26 (53) | 73 | <.001 |
| No | 45 (94) | 39 (67) | 30 (55) | 23 (47) | 137 | |
| Steroid injection | ||||||
| Yes | 7 (15) | 16 (28) | 11 (20) | 9 (18) | 43 | .4 |
| No | 41 (85) | 42 (72) | 44 (80) | 40 (82) | 167 | |
| HT | ||||||
| Yes | 7 (15) | 10 (17) | 4 (7) | 6 (12) | 27 | .4 |
| No | 41 (85) | 48 (83) | 51 (93) | 43 (89) | 183 | |
| Orthosis | ||||||
| Yes | 17 (35) | 28 (48) | 26 (47) | 21 (43) | 92 | .55 |
| No | 31 (65) | 30 (52) | 29 (53) | 28 (57) | 118 | |
| HT and orthosis | ||||||
| Yes | 18 (38) | 30 (52) | 28 (51) | 21 (43) | 97 | .4 |
| No | 30 (63) | 28 (48) | 27 (49) | 28 (57) | 113 | |
∗ Frequencies may not add up to 100 within subgroups due to rounding
† P value represents chi-square test
‡ Additional testing after may include magnetic resonance imaging, ultrasound, repeat EDS, computed tomography, or x-ray diagnostic tests performed after the initial EDS.
Unlike with utilization of surgical treatment, there was no clear relationship between severity and nonsurgical treatments. The frequency of corticosteroid injection was highest in patients with mild severity (28%), followed by moderate (20%), severe (18%), and normal (15%) (P = .4). Hand therapy and orthoses were recommended in over half of the patients with mild (52%) and moderate (51%) EDS findings, which was slightly higher than the recommendation of HT/orthosis wear for patients with severe (43%) and normal (38%) EDS severity. The differences in corticosteroid injection and HT/orthosis use between severity groups was not statistically significant in bivariate analysis (Table 2).
Among all patients of varying severity who received CTR (n = 73), patients had a median wait time of 77 days (interquartile range [IQR], 37–213) between EDS and CTR. There was an inverse relationship between wait time to surgery and severity of the EDS findings. Patients with normal EDS findings (3 of 48 received surgery) had the longest median wait time of 265 days (IQR, 37–1,102) between EDS and CTR, followed by patients with mild severity (170 days; IQR, 87––415; 19 of 58 mild patients), moderate severity (77 days; IQR, 42–292; 25 of 55 moderate patients), and severe EDS results (59.5 days; IQR, 30–81; 26 of 49 severe patients) (P = .02).
In the multivariable analysis, patients with moderate and severe EDS findings had a significantly higher odds of receiving CTR after EDS (odds ratio [OR[, 2.48; 95% confidence interval [95% CI, 1.04–5.93 and OR, 3.79; 95% CI, 1.51–9.50, respectively) relative to the reference group of patients with mild EDS severity. Patients with normal EDS severity had significantly lower odds of receiving CTR as a treatment (OR, 0.11, 95% CI, 0.03–0.43) relative to patients with mild EDS severity. Patients with Medicare insurance were significantly less likely to receive CTR than patients with private insurance (OR, 0.38; 95% CI, 0.15–0.97). We found no significant difference in the odds of receiving CTR among other insurance types (Medicaid, governmental insurance, and workers’ compensation) relative to patients with private insurance. The odds of receiving steroid injection and HT/orthosis treatment was not significantly different between the groups based on severity of EDS findings (Table 3).
Table 3Multivariable Logistic Regression of Postelectrodiagnostic Testing Treatments
| Independent Variable | CTR (n = 206) | Steroid Injection (n = 204) | HT/Orthosis (n = 199) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | P | OR | 95% CI | P | OR | 95% CI | P | |
| Age (continuous) | 0.99 | 0.96–1.03 | .71 | 1.02 | 0.99–1.04 | .21 | |||
| Sex | |||||||||
| Female | Reference | Reference | Reference | ||||||
| Male | 0.45 | 0.21–0.94 | .03 | 0.90 | 0.40–2.02 | .79 | 0.93 | 0.48–1.79 | .83 |
| Race/ethnicity | |||||||||
| Caucasian | Reference | Reference | Reference | ||||||
| African American | 1.00 | 0.35–2.90 | >.99 | 0.96 | 0.31–2.97 | .94 | 1.59 | 0.63–4.01 | .33 |
| Hispanic or Latino | 1.14 | 0.22–6.03 | .88 | 5.69 | 1.46–22.26 | .01 | 2.80 | 0.76–10.35 | .12 |
| Asian | 0.42 | 0.04–4.78 | .49 | 1.87 | 0.15–22.64 | .62 | - | - | - |
| American Indian | - | - | - | - | - | - | - | - | - |
| Other | - | - | - | 2.96 | 0.16–54.09 | .46 | - | - | - |
| Unspecified | - | - | - | - | - | - | - | - | - |
| Insurance type | |||||||||
| Private insurance | Reference | Reference | Reference | ||||||
| Medicare | 0.38 | 0.15–0.97 | .04 | 1.45 | 0.55–3.81 | .32 | 0.72 | 0.32–1.61 | .42 |
| Medicaid | 0.38 | 0.12–1.18 | .09 | 1.74 | 0.52–4.69 | .43 | 0.50 | 0.18–1.38 | .18 |
| Governmental insurance | 2.02 | 0.50–8.20 | .33 | 2.05 | 0.55–7.70 | .29 | 0.93 | 0.27–3.23 | .91 |
| Workers’ compensation | 0.44 | 0.03–5.70 | .53 | - | - | - | - | - | - |
| Unspecified | 1.04 | 0.21–5.05 | .96 | 2.53 | 0.55–11.53 | .23 | 1.55 | 0.37–6.46 | .55 |
| EDS severity | |||||||||
| Normal | 0.11 | 0.03–0.43 | .001 | 0.37 | 0.12–1.12 | .08 | 0.59 | 0.26–1.37 | .22 |
| Mild | Reference | Reference | Reference | ||||||
| Moderate | 2.48 | 1.04–5.93 | .04 | 0.83 | 0.32–2.13 | .69 | 0.92 | 0.40–2.09 | .84 |
| Severe | 3.79 | 1.51–9.50 | .005 | 0.64 | 0.24–1.74 | .38 | 0.61 | 0.26–1.43 | .26 |
∗ Age was removed from the steroid injection model based on number of patients receiving the outcome of interest (n = 43) to avoid overfitting.
Discussion
In this study, we found that CTS patients commonly received surgical and nonsurgical treatments across all EDS severity groups. Whereas it is intuitive that odds of receiving CTR was related to increased EDS severity, a similar or inverse relationship was not seen for receipt of nonsurgical treatments. The odds of receiving steroid injection and HT/orthosis post-EDS was not significantly different between severity groups. Although the frequency of CTR increased with EDS severity, approximately half of patients in both the moderate and the severe groups did not receive surgical treatment. Furthermore, wait time between EDS and CTR was inversely correlated with EDS severity, with severe EDS patients having the shortest time between testing and surgery.
Previous studies have debated the utility of routinely grading CTS severity by EDS criteria given that nerve conduction study results often are not correlated to severity of symptoms.
14
,15
,17
However, other authors have argued that EDS severity has value for prognosis and for assessment of treatment outcomes.13
,28
Although our study did not examine the correlation between EDS grading and clinical examination, the findings suggest that electrodiagnostic CTS severity likely has some impact on the patient’s receipt of surgery and prioritizing timing to surgery. Whereas numerous studies have evaluated the association between EDS severity and postsurgical outcomes, to our knowledge no previous studies have examined the impact of EDS severity on subsequent treatment utilization and timing of surgery for CTS. Our findings showed that EDS severity did not have a clear relationship with the frequency of utilizing nonsurgical treatments, and patients with less-severe EDS findings have prolonged time to surgical treatment among patients who ultimately receive CTR, potentially as a result of a trial of nonsurgical treatment.Although the 2016 AAOS CPG no longer recommends EDS as a confirmatory diagnostic test for patients being considered for surgery as it had in the past, some primary care providers or hand surgeons may continue to routinely order EDS prior to surgical referral.
7
Meanwhile, some physicians may only consider more invasive treatment options based on EDS severity4
or use testing as a factor to predict prognosis. Our study found that slightly less than half of patients with moderate or severe EDS severity did not receive surgery. Therefore, the impact of EDS testing is unclear, particularly in nearly half of the patients with severe findings who did not receive surgical treatment. It is possible that some physicians believe that patients with severe EDS findings do not have a chance for nerve or symptom recovery and do not request a consultation for a surgical evaluation or that patient preference is against surgical intervention. In addition, many patients in the severe group received nonsurgical treatments, which are unlikely to provide long-term benefit.31
From the current study, we conclude that EDS severity had an influence on surgical decision making for some, but that EDS severity is likely not the only consideration for many patients receiving surgical and nonsurgical treatment for CTS. These findings highlight a potential need to provide guidance to referring physicians based on severity of both clinical symptoms and nerve conduction studies to align treatments based on severity, long-term benefit, and patient preferences. Furthermore, in some cases, confirmatory tests may be avoided if patient preference is such that they do not intend to act on the results and the diagnosis is clear from history and examination alone.Our study has several limitations. The study cohort was from a single institution, which may not be representative of all hand surgery practices and patients. However, because our study assessed the relationship between EDS severity, treatments rendered, and timing, it could be a foundation for future study, particularly around the decision making of treatments for patients with severe CTS. Clinical information was not completely available from the medical chart review, including a reliable grading of clinical symptom severity, the reasons for long wait times, or the impact of individual physicians or systems factors on treatment decisions and timing. However, we have excluded patients referred from outside of the institution and patients with incomplete clinical information to minimize the impact of systems-level confounders on data collection. It is also possible to miss post-EDS treatments and tests if they were not documented in the medical record. Owing to the retrospective study design, we were unable to assess whether the patients with normal EDS results truly had CTS except that they had encounters with a CTS diagnosis code identified in billing data and a diagnosis of CTS mentioned in physician progress notes. However, it is possible that these patients with normal EDS findings were misdiagnosed as having CTS. Furthermore, we do not know the reasons behind ordering EDS prior to surgical or nonsurgical treatments. We know from prior studies that routine use of EDS is a common practice of referring providers and surgeons.
7
,32
However, an understanding of the rationale of this practice is outside of the scope of this study. The study requires a much greater sample size to detect a significant difference between severity groups and use of steroid injection or HT/orthosis treatments (a small effect size of these 2 comparisons with chi-square test [effect size = 0.12] in post hoc power calculations would require a sample size of approximately 785 patients for power of 0.8). Despite the limited power, these findings are notable in that patients with severe EDS findings have steroid injection use and HT/orthosis recommendations on a similar magnitude as the other 3 groups, suggesting that use of nonsurgical treatments did not appear to be guided by severity and likelihood of long-term benefit. Lastly, we were unable to determine the causality of EDS severity and CTS-related treatments, but our study showed an association between severity and receipt and timing of surgical treatment.Despite these limitations, this study demonstrated that CTS patients with severe EDS findings had a shorter time to surgery and higher rates of receiving surgical treatment than patients with less-severe EDS findings. However, about 50% of patients with severe EDS findings did not receive surgery and there was no clear relationship between degree of severity and receipt of nonsurgical treatments. These findings may signal a need to critically evaluate the value of nonsurgical treatments in patients with severe EDS findings and the degree that EDS testing influences treatment decisions beyond clinical findings. To improve health care value, physicians must consider the impact of tests on treatment decisions and the long-term benefit of nonsurgical treatments.
Acknowledgments
The study was supported in part by American Foundation for Surgery of the Hand Clinical Research Grant under Award Number N022105, and Career Development Award Number IK2 HX002592 from the U.S. Department of Veterans Affairs Health Services R&D (HSRD) Service (to E.D.S.).
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Article info
Publication history
Published online: October 30, 2020
Accepted:
August 25,
2020
Received:
August 26,
2019
Footnotes
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Identification
Copyright
© 2021 by the American Society for Surgery of the Hand. All rights reserved.
