aaos

Diagnosis of Carpal TunnelSyndrome

Abstract

This clinical practice guideline was created to improve patient careby outlining the appropriate information-gathering and decision-making processes involved in managing the diagnosis of carpaltunnel syndrome. The methods used to develop this clinicalpractice guideline were designed to combat bias, enhancetransparency, and promote reproducibility. The guideline’srecommendations are as follows: The physician should obtain anaccurate patient history. The physician should perform a physicalexamination of the patient that may include personal characteristicsas well as performing a sensory examination, manual muscletesting of the upper extremity, and provocative and/ordiscriminatory tests for alternative diagnoses. The physician mayobtain electrodiagnostic tests to differentiate among diagnoses.This may be done in the presence of thenar atrophy and/orpersistent numbness. The physician should obtain electrodiagnostictests when clinical and/or provocative tests are positive andsurgical management is being considered. If the physician orderselectrodiagnostic tests, the testing protocol should follow theAmerican Academy of Neurology/American Association ofNeuromuscular and Electrodiagnostic Medicine/American Academyof Physical Medicine and Rehabilitation guidelines for diagnosis ofcarpal tunnel syndrome. In addition, the physician should notroutinely evaluate patients suspected of having carpal tunnelsyndrome with new technology, such as magnetic resonanceimaging, computed tomography, and pressure-specifiedsensorimotor devices in the wrist and hand. This decision wasbased on an additional nonsystematic literature review followingthe face-to-face meeting of the work group.

Overview and Rationale

This clinical practice guideline wasapproved by the American Academyof Orthopaedic Surgeons (AAOS) inMay 2007. The AAOS created thisclinical practice guideline to improvepatient care by outlining the appro-priate information-gathering anddecision-making processes involvedin managing the diagnosis of carpal

tunnel syndrome (CTS). Many Amer-icans experience symptoms of CTSand expect relief from the condition,which can be accomplished onlywith proper diagnosis. If the CTS isdiagnosed early, we expect better re-sults of treatment.

For the purpose of this guideline,CTS is defined as a symptomaticcompression neuropathy of the me-dian nerve at the level of the wrist,

Michael Warren Keith, MD

Victoria Masear, MD

Kevin Chung, MD, MS

Kent Maupin, MD

Michael Andary, MD, MS

Peter C. Amadio, MD

Richard W. Barth, MD

William C. Watters III, MD

Michael J. Goldberg, MD

Robert H. Haralson III, MD,MBA

Charles M. Turkelson, PhD

Janet L. Wies, MPH

This clinical practice guideline wasapproved by the American Academy ofOrthopaedic Surgeons.

J Am Acad Orthop Surg 2009;17:389-396

Copyright 2009 by the AmericanAcademy of Orthopaedic Surgeons.

AAOS Clinical Practice Guideline Summary

June 2009, Vol 17, No 6 389

characterized physiologically by evi-dence of increased pressure withinthe carpal tunnel and decreased func-tion of the nerve at that level. CTScan be caused by many different dis-eases, conditions and events. It ischaracterized by patients as produc-ing numbness, tingling, hand andarm pain and muscle dysfunction.The disorder is not restricted by age,sex, ethnicity, or occupation and isassociated with or caused by sys-temic disease and local mechanicaland disease factors.

The AAOS clinical practice guide-lines are developed using evidence-based methods, and the recommen-dations in them are based onsystematic reviews of the availableliterature. The purpose of systemati-cally performing a review is to com-bat bias. Substantial documentationaccompanies the guideline to ensurethat the recommendations are, in-

deed, unbiased. Ideally, those whowish to perform an “intellectual au-dit” of a guideline can examine thisdocumentation and independentlyarrive at the same recommendations.

Because systematic reviews combatbias, the studies included in them arenot chosen on the basis of whetherthey were published by an expert.Similarly, the physician work groupmembers who prepared this guide-line did not begin work on it by ex-changing articles from their personalfiles. Rather, articles were identifiedusing comprehensive searches of sev-eral electronic databases and wereincluded in the guideline only whenthey met specific criteria that weredeveloped before work on the guide-line began.

To further combat bias, the infor-mation extracted from published ar-ticles did not include the conclusionsof the articles’ authors (who, them-

selves, might be biased). Rather, thefocus of the guideline and the sys-tematic review upon which it isbased is on the data and how theywere collected. Thus, information forthe guideline was principally derivedfrom information contained in an ar-ticle’s Methods and Results sections.A total of 224 full articles were re-viewed for this guideline, 24 ofwhich were ultimately concluded.

These systematic reviews were con-ducted between August 2006 andMarch 2007. They identify good evi-dence as well as circumstances inwhich evidence is lacking. They alsoidentify topics for future research toimprove the treatment of patientswith osteoarthritis of the knee.AAOS staff and the Carpal TunnelSyndrome Guideline Work Groupsystematically reviewed the availableliterature and subsequently wrote thefollowing recommendations based

Dr. Keith is Professor, Orthopaedics and Biomedical Engineering, and Chief, Hand Surgery Service, MetroHealth Medical Center,Case Western Reserve University, Cleveland, OH. Dr. Masear is Orthopaedic Surgeon, Orthopaedic Specialists of Alabama,Birmingham, AL. Dr. Chung is Professor, Plastic Surgery, University of Michigan Department of Surgery, University of MichiganMedical Center, Ann Arbor, MI. Dr. Maupin is Orthopaedic Surgeon, Michigan Hand Center, Grand Rapids, MI. Dr. Andary isProfessor, Department of Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI. Dr. Amadio isOrthopaedic Surgeon, Mayo Clinic, and Professor of Orthopedics, Mayo Clinic College of Medicine, Rochester, MN. Dr. Barth isChief, Section of Orthopaedic Surgery, and Chief, Section of Hand Surgery, Sibley Memorial Hospital, Washington, DC, and amember of the Board of Councilors, American Academy of Orthopaedic Surgeons, Rosemont, IL. Dr. Watters is OrthopaedicSurgeon, Bone and Joint Clinic of Houston, Houston, TX. Dr. Goldberg is Chief, Skeletal Dysplasia Clinic, Seattle Children’s Hospital,Seattle, WA. Dr. Haralson is Executive Director of Medical Affairs, American Academy of Orthopaedic Surgeons. Dr. Turkelson isDirector, Department of Research and Scientific Affairs, American Academy of Orthopaedic Surgeons. Ms. Wies is Manager, ClinicalPractice Guidelines Unit, American Academy of Orthopaedic Surgeons.

Dr. Masear or a member of her immediate family serves as a board member, owner, officer, or committee member of the AmericanSociety for Surgery of the Hand and is affiliated with the publication The American Journal of Orthopedics. Dr. Chung or a member ofhis immediate family has received research or institutional support from Stryker. Dr. Andary or a member of his immediate family is amember of a speakers’ bureau or has made paid presentations on behalf of Pfizer and Allergan. Dr. Amadio or a member of hisimmediate family serves as a board member, owner, officer, or committee member of the Orthopaedic Research Society, andImmanuel St. Joseph Hospital; is affiliated with the publication/publishers Journal of Orthopaedic Research and Saunders/Mosby-Elsevier; has received research or institutional support from Musculoskeletal Transplant Foundation and the National Institutes ofHealth (NIAMS and NICHD); has stock or stock options held in Johnson & Johnson, Merck, and Procter & Gamble; and has receivednonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such aspaid travel) from the Journal of Bone and Joint Surgery American. Dr. Barth or a member of his immediate family has stock or stockoptions held in Amgen, Merck, and Pfizer. Dr. Watters or a member of his immediate family serves as a board member, owner,officer, or committee member of Bone and Joint Decade USA, North American Spine Society, Intrinsic Therapeutics, Work Loss DataInstitute, and American Board of Spine Surgery; is affiliated with the publication The Spine Journal; serves as a paid consultant to oris an employee of Blackstone Medical, Medtronic Sofamor Danek, Stryker, Intrinsic Therapeutics, and McKessen Health CareSolutions; and has stock or stock options held in Intrinsic Therapeutics. Dr. Goldberg is affiliated with the Journal of PediatricOrthopedics and the Journal of Children’s Orthopaedics. Dr. Haralson or a member of his immediate family serves as a paidconsultant to or is an employee of Medtronic and Medtronic Sofamor Danek and has stock or stock options held in Orthofix.Ms. Wies or a member of her immediate family has stock or stock options held in Shering Plough. None of the following authors or amember of their immediate families has received anything of value from or owns stock in a commercial company or institution relateddirectly or indirectly to the subject of this article: Dr. Keith, Dr. Maupin, and Dr. Turkelson.

Diagnosis of Carpal Tunnel Syndrome

390 Journal of the American Academy of Orthopaedic Surgeons

on a rigorous, standardized process.Musculoskeletal care is provided in

many different settings by many dif-ferent providers. We created thisguideline as an educational tool toguide qualified physicians through aseries of treatment decisions in an ef-fort to improve the quality and effi-ciency of care. This guideline shouldnot be construed as including allproper methods of care or excludingmethods of care reasonably directedto obtaining the same results. The ul-timate judgment regarding any spe-cific procedure or treatment must bemade in light of all circumstancespresented by the patient and theneeds and resources particular to thelocality or institution.

Methods

The methods used to develop thisclinical practice guideline were de-signed to combat bias, enhancetransparency, and promote reproduc-ibility. Their purpose is to allow in-terested readers the ability to inspectall of the information the workgroup used to reach all of its deci-sions and to verify that these deci-sions are in accord with the bestavailable evidence. The draft of thisguideline was subject to peer reviewand public commentary, and it wasapproved by the AAOS Evidence-Based Practice Committee; Guide-lines and Technology Committee;Council on Research, Quality Assess-ment and Technology; and the Boardof Directors. The methods used toprepare this guideline are detailed inthe full clinical practice guideline,which is available at http://www.aaos.org/research/guidelines/CTS_guideline.pdf.1

Grading theRecommendations

Full interpretation of the recommen-dations in this guideline depends on

understanding the grade assigned toeach recommendation. These gradesare the following:

A: Good evidence (level I studieswith consistent findings) for oragainst recommending intervention.

B: Fair evidence (level II or III stud-ies with consistent findings) for oragainst recommending intervention.

C: Poor-quality evidence (level IVor V) for or against recommendingintervention.

I: There is insufficient or conflictingevidence not allowing a recommenda-tion for or against intervention.

Recommendations

Recommendation 1: Historyof Present Illness

Recommendation 1.1The physician should obtain an accu-rate patient history. Several broadquestions may solicit reports of handnumbness or hand/wrist pain and/orsymptoms. These include

a. Duration: How long have thesymptoms been present?

b. Severity/character: How severeare the symptoms? When do symp-toms occur (eg, nighttime)? Describesymptom quality (eg, tingling, burn-ing, aching). Is the numbness/tinglingintermittent or persistent? What im-proves (eg, shaking the hand, hold-ing hand down, warm water) or ex-acerbates (eg, driving, holding atelephone, using vibratory tools)symptoms?

c. Location/radiation: What is thelocation of the pain and/or numb-ness? Are the symptoms in the me-dian nerve distribution of thehand(s)? If the symptom is not focal,does it radiate to a specific area ofthe body? Are there any other associ-ated symptoms (eg, numbness in thefeet; symptoms in the neck, shoulder,and more proximal in the arm;weakness, clumsiness, droppingthings)?

d. Pace of illness: Is the problem

getting better, worse, or staying thesame? If it is changing, what hasbeen the rate of change?

e. Previous treatment: What hasbeen done and what makes it better(eg, splint, injections, therapy, activ-ity modification, medications)?

f. Lifestyle and activities: Whathand activities are common for thepatient (eg, hobbies, occupation)?Are there functional limitations dueto these symptoms?

Grade of Recommendation: CObtaining a history relating to

CTS serves to assist in diagnosing thedisease and planning appropriatetreatment options. A high level of ev-idence is not available in the litera-ture to assess the diagnostic utility ofhistory data and the predictive valueof the data in evaluating severity ofdisease and outcomes of treatment.Therefore, the work group employedexpert opinion in creating this rec-ommendation to guide physicians inthe appropriate questions thatshould be asked during patient en-counters to improve diagnosis.

It is unclear from the literaturewhether the duration of symptomscorrelates with the amount of nerveinjury or can predict treatment out-comes. It is also unclear whether theseverity and character of symptomsare related to the structural andphysiologic condition of the mediannerve. The evidence from availablestudies does not illustrate a direct re-lationship between symptoms andelectrodiagnostic test results eitheracross all studies (regardless of de-sign) or by looking at results for asingle electrodiagnostic test. Symp-toms such as numbness along thedistribution of the median nerve, in-creasing symptoms at night whensleeping, improvement of symptomsby shaking the hand, and symptomexacerbation when driving or hold-ing a telephone are classic symptomsthat in combination may be highlysuggestive of CTS.

Michael Warren Keith, MD, et al

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Identification of the location andradiation of symptoms may excludeor include other diagnoses, such asproximal nerve compression syn-drome, that may mimic CTS. Havingthese associated symptoms may alertthe physician to look for diagnosesother than CTS.

The symptoms of CTS may vary ona daily basis. Understanding the diseaseprogression can be helpful in determin-ing the appropriate diagnosis and treat-ment plan. For symptoms that are notincreasingly severe but vary periodically,conservative management may be help-ful in diagnosis.

Understanding patient response toprevious treatment may verify the di-agnosis of CTS and may support pa-tient progression to carpal tunnelsurgery. Response to conservativetreatment varies. If the physicianuses steroid injection, the greatestpatient improvement is seen at 1month. If the physician uses conser-vative management and measuresimprovement with electrodiagnostictests, the greatest improvement is be-tween 3 and 6 months, as seen bychange in distal motor latency mea-surements (ms) (Figure 102 in theClinical Guideline2).

In summary, the work group usedexpert opinion to formulate Recom-mendation 1 for obtaining appropri-ate history to make the diagnosis ofCTS. Based on the level of evidencefor the studies that reviewed conser-vative management, the work grouprates this recommendation at a Clevel, which indicates poor quality ofevidence consisting of level II, III, orIV data for or against recommendingintervention (Table 123 and Figure 82

in the Clinical Guideline).

Recommendation 2:Physical ExaminationThe physician should perform aphysical examination of the patientthat may include

a. Personal characteristics (eg, age,sex, weight, height, body habitus)

b. Range of motion of hand/wristc. Observation of deformity, swell-

ing, atrophy, skin trophic changesd. Pinch/grip strengthe. Hand diagramf. Sensory examination (eg, two-point

discrimination, Semmes-Weinsteinmonofilament, vibrometry, texturediscrimination)

g. Manual muscle testing of the up-per extremity (eg, examine for mus-cular atrophy, especially in the the-nar muscle group)

h. Provocative tests (eg, Phalentest, Tinel sign, median nerve com-pression test, reverse Phalen test)

i. Discriminatory examination foralternative diagnoses (eg, radiculopa-thy, neuropathy, pain syndromes, ar-thritis, tendinitis, vascular abnormal-ities)

Level of Evidence: VGrade of Recommendation: CPersonal characteristics such as

age, sex, height, weight, and bodyhabitus are basic information thatare important for fulfilling the evalu-ation and management documenta-tion. Included in parts of this evalua-tion would be determination ofvascular status, obvious deformity,and testing for other related condi-tions (eg, basilar thumb arthritis, deQuervain disease, cubital tunnel syn-drome, cervical radiculopathy).

Sensory examination using, for ex-ample, two-point discrimination,Semmes-Weinstein monofilament, vi-brometry, and texture discrimina-tion, is important for defining theanatomic distribution of sensorychanges. Sufficient evidence does notexist from the literature reviewed forthis guideline to recommend one testover another or to suggest the overallutility of a test in diagnosing CTS.Future research will be required toconfirm the diagnostic utility of thesetests.

Manual muscle testing of the upper

extremity, including evaluation forobvious muscle atrophy, is impor-tant, especially for the thenar musclearea. Thenar atrophy has been re-ported to have a high predictivevalue in CTS, but its appearance canbe rare.4 This literature review con-tained only two primary studies4,5

that specifically addressed thenar at-rophy. No conclusion on the diag-nostic value of thenar atrophy can bedrawn conclusively from two stud-ies.

Several provocative tests should beconsidered to aid in the evaluationand diagnosis of CTS. For multiplereasons (ie, poor study design, vari-ability in study results, inconsistentdata, few studies examining the sametests, small datasets for each test), noone test has been identified as a goldstandard for identifying CTS. Phalentest results ranged in sensitivity from0.46 to 0.80 and in specificity from0.51 to 0.91.5-8 The Tinel sign rangedin sensitivity from 0.28 to 0.73 andin specificity from 0.44 to 0.95.4-7

The median nerve compression testranged in sensitivity from 0.04 to0.79 and in specificity from 0.25 to0.96.5,8,9 Combining the results ofmore than one provocative testmight increase the sensitivities andspecificities. For example, combinedresults of the Phalen and mediannerve compression tests yielded asensitivity of 0.92 and a specificity of0.92;8 however, further literaturewould be required to confirmwhether this result is diagnosticallyaccurate.

The reverse Phalen test, tetheredmedian nerve stress test, and thetourniquet test have been evaluatedonly a few times, leaving insufficientevidence from which to draw anyconclusions as to their accuracy inthe diagnosis of CTS.4-6

The clinical tests for CTS by them-selves do not reliably diagnose CTS.Similarly, as will be discussed inRecommendation 3, electrodiagnos-



tic studies by themselves also do notreliably diagnose CTS. However,when the symptoms, clinical tests,and electrodiagnostic tests are com-bined, statistical significance (P <0.05) is obtained compared withpostsurgical outcomes. Among surgi-cal candidates, clinical tests and elec-trodiagnostic studies correlated withpositive postsurgical outcomes (Fig-ures 96 through 99 in the ClinicalGuideline2).

Although CTS cannot be diag-nosed primarily on clinical or elec-trodiagnostic grounds, the evidenceshows that a combination of the twocan better confirm the diagnosis andprovide treatment orientation vis-à-vis carpal tunnel release. These com-bination tests vary considerablyamong the studies. For example:

Haupt et al:10 (motor and sensorytests) + (distal motor latency of themedian nerve, antidromic sensorynerve conduction velocity [NCV],electromyography [EMG] examina-tion of abductor pollicis brevis)

Braun and Jackson:11 (range of mo-tion, grip strength, pinch strength,monofilament sensory evaluation,Phalen, Tinel) + (sensory latency>3.5 ms)

Glowacki et al:12 (Phalen or Tinel)+ (motor latencies >4.0 ms, sen-sory latencies >3.7 ms, amplitudes<20 μV, or a conduction velocity <50m/s with evidence of fibrillation)

Boniface et al:13 (sensory tests) +(prolonged median sensory conduc-tion velocity, distal motor latency toabductor pollicis brevis)

Given the small number of studiesin the diagnostic groupings illus-trated in these examples, definitivecombinations of clinical and elec-trodiagnostic tests that provide thebest performance could not be iden-tified. Future research should com-pare the diagnostic accuracy of dif-ferent combinations of tests toidentify and recommend specific testcombinations.

Other conditions may present withsymptoms similar to those found inCTS (eg, cervical radiculopathy, hy-pothyroidism, peripheral neuropa-thy, wrist/trapeziometacarpal arthro-sis, wrist tendinitis/tenosynovitis,Raynaud disease, arterial injury orthrombosis, nerve laceration, neu-roma, brachial plexus injury, othernerve entrapment syndromes, painsyndromes). Physical examinationshould include other areas of the up-per extremity and neck that may re-late to these alternative diagnoses.This may include the following:

1. Muscular atrophy or weaknessof the shoulder, elbow, wrist, thumband/or fingers

2. Active range of motion, particu-larly for the wrist and digits

3. Swelling, masses, and/or tender-ness around the wrist or digits

4. Capillary refill, radial and ulnarpulses, Allen test

5. Wounds or scars on the upperextremity

6. Cervical spine range of motion,Spurling sign

7. Thyroid enlargement8. Radiographs of the wristThese recommendations were

formed by expert opinion of thework group; no literature searcheswere performed to support these rec-ommendations.

Recommendation 3: NerveConduction VelocityStudies

Recommendation 3.1aThe physician may obtain electrodi-agnostic tests to differentiate amongdiagnoses.

Recommendation 3.1bThe physician may obtain electrodi-agnostic tests in the presence of the-nar atrophy and/or persistent numb-ness.

Level of Evidence: VGrade of Recommendation: C

There were no prospective studiesthat evaluated a broad spectrum ofpatients. In addition, there was noconsistent independent referencestandard (including atrophy and per-sistent numbness) used across stud-ies, and none attempted to differenti-ate CTS from other diagnoses. Therewere multiple studies differentiatingCTS patients from normal subjects,mainly as case-control or cohortstudies (Figures 5 and 9 in the Clini-cal Guideline2). There were consider-able problems with spectrum biasand lack of a gold standard for diag-nosis. Thus, the quality of studies fellto level V, or expert opinion. Despitethis, there was expert opinion that,in some cases, NCV studies and nee-dle EMG can differentiate CTS fromother peripheral nerve problems (eg,polyneuropathy, brachial plexopathy,cervical radiculopathy). Additionally,thenar atrophy and/or persistentnumbness may suggest severe nerveinjury, which may warrant more ag-gressive management or diagnosticevaluation. NCV study and EMGcan assist in documenting this severenerve injury.

Recommendation 3.1cThe physician should obtain elec-trodiagnostic tests if clinical and/orprovocative tests are positive andsurgical management is being consid-ered.

Levels of Evidence: II and IIIGrade of Recommendation: BImprovement in symptoms after sur-

gical release is a clinically relevant ref-erence standard that is important to pa-tient care and patient management.Four studies11-14 found a correlationbetween a combination of clinicalpresentation (symptoms and Phalentest or Tinel sign) and nerve conduc-tion studies with good surgical out-come (Figure 98 in the ClinicalGuideline2). See the meta-regressionof surgical outcome and clinical andelectrodiagnostic tests (Figure 99 in


June 2009, Vol 17, No 6 393

the Clinical Guideline2). The associa-tion with clinical tests alone or elec-trodiagnostic tests alone did not havea statistically significant associationwith surgical outcome (Figures 96and 97 in the Clinical Guideline2).There were no other high-qualitystudies that attempted to correlateoutcomes of other treatments (eg,splinting, steroid injections) withpretreatment diagnostic results.Good response to surgery does notprove the diagnosis of CTS becauseother factors may provide symptomrelief (eg, placebo, surgery activitymodification, postoperative splint-ing). However, postsurgical improve-ment is a clinically relevant outcome.Clinicians who are considering surgi-cal management should know thatgood surgical outcome is correlatedwith a combination of positive clini-cal and positive electrodiagnostictests.10-14 Again, it is important tonote that the evidence shows a statis-tically significant association be-tween the combination of clinicaltests, electrodiagnostic testing, andpositive surgical outcomes (Figures96 through 99 in the Clinical Guide-line2).

The literature does not permit cal-culation of sensitivities and specifici-ties of all tests. Additionally, sensitiv-ity and specificity of NCV studiescannot be determined with absolutecertainty primarily because a diagno-sis of CTS cannot be made with ab-solute certainty without a gold stan-dard. The lack of a reliable goldstandard and the use of referencestandards that are variable fromstudy to study give disparate results.Further, no universally agreed-upondiagnostic criteria exist for the diag-nosis of CTS. The case-control stud-ies for electrodiagnostic testing con-sistently showed receiver operatingcurves of a very high specificity andvariable sensitivity (Figure 11 in theClinical Guideline2), illustrating in-flated results due to spectrum bias.

The case-control studies are, there-fore, not considered useful.

Few well-designed cross-sectionaland cohort studies were found.Based on the low availability of qual-ity studies as well as the small size ofthe study populations, statisticallysignificant receiver operating curves1

could not be constructed.

Recommendation 3.2If the physician orders electrodiagnos-tic tests, the testing protocol should fol-low the American Academy ofNeurology/American Association ofNeuromuscular and ElectrodiagnosticMedicine/American Academy of Phys-ical Medicine and Rehabilitation (AAN/AANEM/AAPMR) guidelines for diag-nosis of CTS.

a. Sensory NCV studies to the me-dian nerve with distal latency com-pared to the ulnar and radial nerve

b. Median motor nerve conductionin most patients

c. Needle EMG at the discretion ofthe physician

Levels of Evidence: IV and VGrade of Recommendation: CThirteen published studies were

evaluated and met criteria for reviewcompared with a reference standardof signs, symptoms, and one elec-trodiagnostic test. Twelve of thesestudies15-26 were level IV and one27

was level II. The reference standardused included signs, symptoms, anda different electrodiagnostic test thanthe electrodiagnostic test being eval-uated in the study. The index testcould not be part of the referencedstandard, and vice versa. These in-clusion criteria were comparable butslightly different from the criteriaused in the AANEM Practice Param-eter, which the work group agreed touse as a protocol for electrodiagnos-tic testing. The AANEM referencestandard included clinical symptomsand did not include another nerveconduction study.28

The vast majority of studies were

of case-control design, suggestingspectrum bias. A result of spectrumbias is that the sensitivities and speci-ficities are likely inflated. Multiplenerve conduction studies were re-ported in the primary articles. Thesearticles employed 11 different nerveconduction study techniques (Figure6 in the Clinical Guideline2), includ-ing median sensory to ulnar sensorycomparison, median sensory to ra-dial sensory comparison, mixednerve comparison, and median mo-tor testing. A review of these studiesagain could not determine conclu-sively that any of the electrodiagnos-tic tests was clearly superior (Table 3in the Clinical Guideline3). Compari-sons cannot be made, and a test hier-archy cannot be constructed,1 whencase-control studies are used becauseof the probability of spectrum bias.The authors of Diagnosis and Treat-ment of Worker-Related Musculo-skeletal Disorders of the Upper Ex-tremity,29 another evidence-basedsystematic review that examined 31databases and 1,600 journals, foundsimilar conclusions.

The 2002 publication of theAANEM, AAN, and AAPMR,whose protocol is preferred by thework group for electrodiagnostictesting, was an evidence-based re-view of 278 articles, of which 22 metliterature inclusion criteria. This re-view also illustrated that there is noconclusive evidence that one singlestudy has the highest sensitivity orspecificity. It did, however, concludethat median sensory latencies acrossthe wrist compared to ulnar or radiallatencies or proximal median con-duction improved sensitivity as op-posed to absolute median sensory ormotor distal latencies.28

Recommendation 3.3The physician should not routinelyevaluate patients suspected of havingCTS with new technology such asmagnetic resonance imaging (MRI),



CT, and pressure-specified sensori-motor devices (PSSDs).

Level of Evidence: VGrade of Recommendation: CChanges in the appearance of the

median nerve have been reportedwith MRI and CT. Following theface-to-face work group meeting onFebruary 24, 2007, an additionalnonsystematic literature review wascompleted. This review included 6 of25 articles on MRI and no studies onCT. Five of the six articles on MRIwere case-control study designs andtherefore introduced spectrum bias.There is no good evidence to datethat these imaging modalities im-prove sensitivity or specificity inmaking the diagnosis of CTS.29 Inthe opinion of this committee, thereis no role for the routine use of MRIor CT in the diagnosis or manage-ment of CTS. These imaging modali-ties should be reserved for the evalu-ation of related conditions in theappropriate clinical setting (eg, Kien-böck disease, ruling out occult frac-ture, hook of hamate nonunion).

PSSDs have also been described forevaluation of patients with symp-toms of CTS. Two of three studiesinvestigating this technology were in-cluded in this additional literature re-view process. Two studies do notprovide sufficient evidence to pro-vide a recommendation. There is,however, significant experience andliterature supporting the use ofNCV/EMG in the evaluation of CTS.In the opinion of this committee,there is insufficient evidence to sup-port the routine use of PSSDs in theevaluation of CTS at this time.

Future Research

Although every effort has been madeto include studies of the highest evi-dence, high-quality evidence is notreadily available for CTS diagnosisat this time. This guideline has been

hindered by a relative lack of studiesof the best design (ie, level I and IIevidence) and specifically hinderedby an abundance of case-controlstudies (which are subject to spec-trum bias). To achieve a high-qualityliterature base, academic authorsand scientists should invest their timeand effort in studies designed toavoid bias (eg, blinded controlled tri-als that are not case-control studies).Future studies should, from the on-set, be based on improved study de-sign. The recommendations of thisguideline have therefore depended tosome degree on lesser evidence, in-cluding consensus and expert opin-ion. Few studies describe the impactof health policy on process optimiza-tion. Skillful and timely delivery ofCTS care, the access that patientshave to definitive management, andthe choices patients make in themanagement of disease all affect out-comes. Studies of cost burden to thecommunity from a common dis-abling source of productivity lossneed restatement, and future studiesmust address all of these issues.

Although thousands of publica-tions have been written regarding thediagnosis and treatment of CTS,greater precision and transparentmethodology are needed to bring thenext generation of academic papersto the forefront of review so thatthey directly contribute to qualitymedical care. The process of periodi-cally assessing our medical and surgi-cal progress in diagnosing and treat-ing common conditions becomesmore precise each year. A commonprotocol for evaluation of the litera-ture should spur more consistentlysound design and greater health forthe cost of care expended. This clini-cal practice guideline is based onstronger evidence-based analysismethodology than ever previouslyconducted by the AAOS and is there-fore state-of-the-art. The detailsof the statistical methods used in

this guideline are further explainedat http://www.aaos.org/Research/guidelines/CTSdiagnosisguide.asp.30

References

Please note that reference 28 hasbeen withdrawn by the publisher.This does not compromise the integ-rity of the AAOS Clinical PracticeGuideline on the Diagnosis of CarpalTunnel Syndrome.

1. American Academy of OrthopaedicSurgeons: Clinical Guideline onDiagnosis of Carpal Tunnel Syndrome.Rosemont, IL: American Academy ofOrthopaedic Surgeons, May 2007.Available at: http://www.aaos.org/research/guidelines/CTS_guideline.pdf.Accessed March 11, 2009.

2. American Academy of OrthopaedicSurgeons: Clinical Guideline onDiagnosis of Carpal Tunnel Syndrome.Figures. Rosemont, IL: AmericanAcademy of Orthopaedic Surgeons, May2007. Available at: http://www.aaos.org/research/guidelines/CTS_figs.pdf.Accessed March 11, 2009.

3. American Academy of OrthopaedicSurgeons: Clinical Guideline onDiagnosis of Carpal Tunnel Syndrome.Evidence Tables. Rosemont, IL:American Academy of OrthopaedicSurgeons, May 2007. Available at: http://www.aaos.org/research/guidelines/CTS_tables.pdf. Accessed March 11,2009.

4. Gomes I, Becker J, Ehlers JA, Nora DB:Prediction of the neurophysiologicaldiagnosis of carpal tunnel syndromefrom the demographic and clinical data.Clin Neurophysiol 2006;117:964-971.

5. de Krom MC, Knipschild PG, KesterAD, Spaans F: Efficacy of provocativetests for diagnosis of carpal tunnelsyndrome. Lancet 1990;335:393-395.

6. Raudino F: Tethered median nerve stresstest in the diagnosis of carpal tunnelsyndrome. Electromyogr ClinNeurophysiol 2000;40:57-60.

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