Advertisement

Surgeons' Recommendations for Neurodiagnostic Testing With High Pretest Probability of Idiopathic Median Neuropathy at the Carpal Tunnel

      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.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Giladi A.M.
        • Lin I.C.
        • Means K.R.J.
        • Kennedy S.A.
        Applying evidence to inform carpal tunnel syndrome care.
        J Hand Surg Am. 2021; 46: 223-230.e2
        • Fowler J.R.
        • Cipolli W.
        • Hanson T.
        A comparison of three diagnostic tests for carpal tunnel syndrome using latent class analysis.
        J Bone Joint Surg Am. 2015; 97: 1958-1961
        • Bland J.D.
        Do nerve conduction studies predict the outcome of carpal tunnel decompression?.
        Muscle Nerve. 2001; 24: 935-940
        • Basiri K.
        • Katirji B.
        Practical approach to electrodiagnosis of the carpal tunnel syndrome: a review.
        Adv Biomed Res. 2015; 4: 50
        • Kortlever J.T.P.
        • Becker S.J.E.
        • Zhao M.
        • Ring D.
        Borderline nerve conduction velocities for median neuropathy at the carpal tunnel.
        J Hand Surg Am. 2020; 45: 379-388.e1
        • Zyluk A.
        • Szlosser Z.
        The results of carpal tunnel release for carpal tunnel syndrome diagnosed on clinical grounds, with or without electrophysiological investigations: a randomized study.
        J Hand Surg Eur Vol. 2013; 38: 44-49
        • Watson J.
        • Zhao M.
        • Ring D.
        Predictors of normal electrodiagnostic testing in the evaluation of suspected carpal tunnel syndrome.
        J Hand Microsurg. 2010; 2: 47-50
        • Finsen V.
        • Russwurm H.
        Neurophysiology not required before surgery for typical carpal tunnel syndrome.
        J Hand Surg. 2001; 26: 61-64
        • D’Auria J.L.
        • Montanez A.
        • Toirac A.
        • Goitz R.J.
        • Fowler J.R.
        Accuracy of surgeon diagnosis in predicting carpal tunnel syndrome.
        Hand (N Y). 2021; 16: 179-182
        • Graham B.
        The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome.
        J Bone Joint Surg Am. 2008; 90: 2587-2593
        • Billig J.I.
        • Sears E.D.
        Utilization of diagnostic testing for carpal tunnel syndrome: a survey of the American Society for Surgery of the Hand.
        J Hand Surg Am. 2022; 47: 11-18
        • Billig J.I.
        • Kotsis S.V.
        • Chung K.C.
        • et al.
        Variation in use of electrodiagnostic testing: analysis from the Michigan Collaborative Hand Initiative for Quality in Surgery.
        J Hand Surg. 2021; 46: 169-177
        • Glowacki K.A.
        • Breen C.J.
        • Sachar K.
        • Weiss A.P.
        Electrodiagnostic testing and carpal tunnel release outcome.
        J Hand Surg Am. 1996; 21: 117-121
        • Braun R.M.
        • Jackson W.J.
        Electrical studies as a prognostic factor in the surgical treatment of carpal tunnel syndrome.
        J Hand Surg Am. 1994; 19: 893-900
        • Boersma E.
        • Crijns T.
        • Nijhuis-van der Sanden M.
        • Edwards M.
        • Ring D.
        • Janssen S.
        Accuracy and reliability of MRI-reports to determine which shoulder is symptomatic for workers compensation patients with unilateral symptoms.
        J Orthop. 2020; 21: 199-202
        • Kyriakedes J.C.
        • Crijns T.J.
        • Teunis T.
        • Ring D.
        • Bafus B.T.
        Science of Variation Group. International survey: factors associated with operative treatment of distal radius fractures and implications for the American Academy of Orthopaedic Surgeons’ appropriate use criteria.
        J Orthop Trauma. 2019; 33: e394-e402
        • Crijns T.J.
        • Kortlever J.T.P.
        • Guitton T.G.
        • Ring D.
        • Barron G.C.
        Symptoms of burnout among surgeons are correlated with a higher incidence of perceived medical errors.
        HSS J. 2020; 16: 305-310
        • Mellema J.J.
        • Janssen S.
        • Schouten T.
        • et al.
        Intramedullary nailing versus sliding hip screw for A1 and A2 trochanteric hip fractures.
        Bone Joint J. 2021; 103-B: 775-781
        • Nuckols T.K.
        • Conlon C.
        • Robbins M.
        • et al.
        Quality of care and patient-reported outcomes in carpal tunnel syndrome: a prospective observational study.
        Muscle Nerve. 2018; 57: 896-904
        • The American Academy of Orthopaedic Surgeons
        Management of Carpal Tunnel Syndrome. Evidence-Based Clinical Practice Guideline.
        • Blumenthal-Barby J.S.
        • Krieger H.
        Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy.
        Med Decis Making. 2015; 35: 539-557
        • Rousseau A.
        • Rozenberg P.
        • Ravaud P.
        Assessing complex emergency management with clinical case-vignettes: a validation study.
        PLoS One. 2015; 10e0138663
        • Peabody J.W.
        • Luck J.
        • Glassman P.
        • Dresselhaus T.R.
        • Lee M.
        Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality.
        JAMA. 2000; 283: 1715-1722
        • Mohan D.
        • Fischhoff B.
        • Farris C.
        • et al.
        Validating a vignette-based instrument to study physician decision making in trauma triage.
        Med Decis Making. 2014; 34: 242-252
        • Teunis T.
        • Janssen S.
        • Guitton T.G.
        • Ring D.
        • Parisien R.
        Do orthopaedic surgeons acknowledge uncertainty?.
        Clin Orthop Relat Res. 2016; 474: 1360-1369
        • FAIR Health Consumer
        Estimate your Healthcare Expenses.
        https://www.fairhealthconsumer.org/
        Date accessed: April 29, 2022
        • Glied S.A.
        • Zhu B.
        Catastrophic Out-of-Pocket Health Care Costs: A Problem Mainly for Middle-Income Americans with Employer Coverage. The Commonwealth Fund.
        • Alokozai A.
        • Crijns T.J.
        • Janssen S.J.
        • et al.
        Cost in hand surgery: the patient perspective.
        J Hand Surg. 2019; 44: 992.e1-992.e26
        • Kortlever J.T.P.
        • Zhuang T.
        • Ring D.
        • Reichel L.M.
        • Vagner G.A.
        • Kamal R.N.
        Does societal cost information affect patient decision-making in carpal tunnel syndrome? A randomized controlled trial.
        Hand (N Y). 2021; 16: 439-446
        • London Z.N.
        Safety and pain in electrodiagnostic studies.
        Muscle Nerve. 2017; 55: 149-159
        • Porter M.E.
        What is value in health care?.
        N Engl J Med. 2010; 363: 2477-2481
        • Johnson K.M.
        Using Bayes’ rule in diagnostic testing: a graphical explanation.
        Diagnosis (Berl). 2017; 4: 159-167