New treatment guideline for carpal tunnel syndrome is based on current literature

The first AAOS clinical practice guideline may lead to performance measures, CME courses.

The American Academy of Orthopaedic Surgeons recently released a new clinical practice guideline for the treatment of carpal tunnel syndrome.

The guideline represents the first clinical practice guideline from the American Academy of Orthopaedic Surgeons (AAOS) and could serve as a starting point for a national performance measure on the condition.

The guideline is based on a systematic literature review of carpal tunnel syndrome (CTS) treatments and represents a combination of objective and consensus information.

Best practices

“The objective is to create best practices for the treatment of carpal tunnel syndrome and to provide evidence-based medical support for all practitioners,” said Michael W. Keith, MD, chair of the guideline workgroup for the treatment of CTS and of the AAOS Evidence Based Practice Committee. “This guideline will be listed in the National Guidelines Clearing House and will be the starting point for the development of performance measures and practice indicators as well as a source for the development of continuing medical education courses, which will help lead to the maintenance of certification.”

To create the guideline, the workgroup searched four electronic databases and reviewed 332 articles from thousands published.

“It was important for the committee to consider all of the stakeholders in the development of the guideline,” Keith said. “We tried to consider the positions of practitioners, payers, regulators and patients and balance our recommendations so that this guideline was outcome-based. Therefore, it was mostly in favor of the patient’s point of view.”

Recommendations

The guideline includes nine recommendations. Each lists the level of evidence supporting the recommendation and is graded as good, fair, poor or inconclusive based on the evidence for or against the intervention.

Some of the recommendations include the use of the following treatments:

carpal tunnel release;
local steroid injection or splinting; and
oral steroids or ultrasound.

The workgroup also recommended surgical treatment by complete division of the flexor retinaculum, regardless of the technique.

“Surgeons often choose different techniques based on training, experience, the influence of others and the medical literature,” Keith said. “Our group could find no consistent difference or advantage where one technique could be preferred to another. In common, all these techniques accomplished the release of pressure on the median nerve by dividing the flexor retinaculum.”

However, the workgroup found inconclusive evidence regarding some of the following treatments:

medications including NSAIDs;
stretching; and
flexor retinaculum lengthening.

In addition, the group found insufficient evidence to give recommendations for CTS in association with diabetes, pregnancy, hypothyroidism and CTS in the workplace.

Keith noted that the guideline also highlights the need for more studies and better quality research on this topic. “We believe that future research should always consider outcomes in the context of the patient’s experience. The next Centers for Medicare & Medicaid Services task will be to interpret the patient’s experience whether they are satisfied or not with how they are treated,” he said.

Response

The guideline has received praise from some surgeons in the field. “I think it is excellent,” said Barry P. Simmons, MD, a member of the Orthopedics Today Editorial Board. “First of all, it is well done and it really adheres to the goal of evaluating disorders with evidence-based medicine. All of [the evaluators] are well-known for what they do and include not only hand surgeons, but also people who do a lot of evidence-based research.”

He added, “The reader should bear in mind when reviewing the guidelines that they were graded according to the strength of the data.”

A. Lee Osterman, MD, a member of the Orthopedics Today Editorial Board, said that the guideline is reasonable and adequately covers the broad spectrum of patients with CTS. However, he expressed concern that the guideline could be exploited by nonphysician groups.

“I think that one of the problems with this guideline is that it allows insurance companies or [others] to assume that there are absolutes in terms of how we should behave and perform,” Osterman said. “[That] is my concern about guidelines in general. I think that they are helpful overall as long as they are not used as a be-all and end-all.”

For more information:
Michael W. Keith, MD, professor of orthopedics and biomedical engineering, Case Western Reserve University, can be reached at 2500 MetroHealth Drive, Cleveland, OH 44109, 216-778-4399; e-mail: msk@case.edu. A. Lee Osterman, MD, can be reached 700 S. Henderson Rd., #200, King of Prussia, PA 19078; 610-768-4467; e-mail: loster51@bellatlantic.net. Barry P. Simmons, MD, can be reached at Brigham & Women’s Hospital, 75 Francis St., Boston, MA 02115; 617-732-5378; e-mail: bsimmons@partners.org.

References:
www.aaos.org/guidelines
www.ngc.org