Physician's Weekly Surgery Edition Article - New Guidelines for Carpal Tunnel Syndrome

       A recently released, evidence-based clinical practice guideline for carpal tunnel syndrome streamlines possible treatment processes for this debilitating ailment.

      According to the American Academy of Orthopaedic Surgeons (AAOS), the incidence of carpal tunnel syndrome in the United States has been estimated at about 50 cases per 1,000 people in the general population. Each year, one to three new carpal tunnel syndrome cases will develop per 1,000 people. The average lifetime costs associated with the condition are significant, accounting for as much as $30,000 for each injured worker in the U.S. These costs are largely due from lost productivity and the cost of treatment. A study released by the National Center for Health Statistics estimated that 3.1 million people sought help from physicians for the treatment of carpal tunnel syndrome in 2005.

      “Many Americans experience symptoms of carpal tunnel syndrome,” says Michael W. Keith, MD. “It’s one of the most common disorders of the upper extremity and can manifest for a variety of reasons. It’s thought to be caused by increased pressure on the median nerve in the carpal tunnel of the wrist. If left untreated or under-treated, carpal tunnel syndrome may worsen and progress to permanent sensory loss and paralysis in severe cases.”

      The diagnosis of carpal tunnel syndrome is made on the basis of signs, symptoms, and electro-diagnostic tests. “An appropriate diagnosis is a critical factor to providing the most effective treatment,” says Dr. Keith. “Most sufferers expect relief from the condition, which can be accomplished with proper treatment. Many orthopaedic surgeons—including general orthopaedic surgeons as well as hand specialists—will be faced with making important treatment decisions for patients with the condition at some point in their career.”

      Many Treatment Options

      In October 2008, the AAOS released an evidence-based clinical practice guideline for the treatment of carpal tunnel syndrome. “The purpose of the guideline is to provide a method to facilitate decision making in the treatment of the condition,” says Dr. Keith, who chaired the writing committee that developed the guidelines. “An expert review of the literature on carpal tunnel syndrome was performed so that a concise set of recommendations could be created, complete with rationales that can help defend decisions being made by practitioners. The guideline is intended to serve as a starting point for physicians in delivering the highest quality care. It can open up the lines of patient-physician communication on possible treatment options.”

      Dr. Keith says there are many options for physicians to consider when managing patients with carpal tunnel syndrome (Table 1). “It’s imperative that physicians have information about the different techniques that are available for performing carpal tunnel release. In many cases, surgery is not the only treatment option. The AAOS guidelines find that the literature supports the use of conservative techniques, which achieve similar clinical outcomes. There are also important considerations addressed in the guidelines surrounding the use of medications as well as conservative and alternative therapies. It also provides recommendations on reassessing and monitoring patients after therapeutic interventions have been initiated.”

      Interventions to Avoid

      In addition to providing information on available effective treatment options, the AAOS guidelines also identify treatments that are ineffective based on current evidence (Table 2). “Many alternative treatments have been used or considered to treat carpal tunnel syndrome despite having limited or no support in clinical trials,” says Dr. Keith. “For example, clinicians have hoped that vitamin supplements, exercise programs, and other alternative therapies might be effective, but careful analysis suggests that consideration of these approaches is unwarranted until proven effective. More evidence is needed on the role of alternative medicine and physical and occupational therapy as well as bracing techniques and other types of interventions.”

      Updates to Come

      The AAOS guidelines for carpal tunnel syndrome are a dynamic document, and Dr. Keith says it will be revised—just like any other AAOS guideline—every 3 to 5 years. The AAOS is widely disseminating the current guidelines via the internet, both on its own website (www.aaos.org/Research/guidelines/) and on the website of the National Guidelines Clearinghouse (www.ngc.gov). “More clinical trials and reviews on the diagnosis and treatment of carpal tunnel syndrome will be assessed as evidence emerges in the future. In the meantime, patients should be informed that their condition is one that is generally associated with good outcomes. As physicians, we should ensure that our patients are satisfied with their treatment because the condition can be remedied effectively. However, if current treatment approaches are ineffective or unsatisfactory, then other options should be explored. In most cases, carpal tunnel syndrome will be treated expeditiously and effectively with a programmed approach in a short time. There are plenty of treatment options to choose from, and the AAOS guidelines can help practitioners by providing a strong rationale for the selection of treatment.”

      Michael W. Keith, MD, has indicated to Physician’s Weekly that he has received grants/research aid from the NIH.