Updated Carpal Tunnel Practice Guidelines From AAOS

It’s been eight years and a couple hundred of clinical studies since American Academy of Orthopaedic Surgeons (AAOS) last updated Clinical Practice Guidelines for Management of Carpal Tunnel Syndrome (CTS) in 2016.

Time for an update.

“The prior Clinical Practice Guideline was over five years old and there have been a number of well-conducted studies that have advanced our understanding in the diagnosis and treatment of carpal tunnel syndrome that have been published since the prior Clinical Practice Guideline,” Lauren Shapiro, M.D., M.S., co-chair of the guideline development group, told OTW. “These advancements warranted a review of the new literature, as well as new recommendations that highlight high-value approaches to the management of CTS.”

In light of the updated guidelines, OTW asked Dr. Shapiro, assistant professor of orthopedic surgery at the University of California – San Francisco, how she and the guidance development group addressed the dynamic tension between short-term care and long-term solutions. She said: “From a methodologic perspective, it is more difficult and costly to conduct studies evaluating the long-term benefits of various treatment options so there are typically fewer of them published as compared to studies evaluating short term benefits.”

“However, as the U.S. healthcare system transitions to one that focuses on quality, value, and patient-centered care, the importance of long term, durable outcomes becomes more clear. For example, we chose to ask questions that would inform the discussion a physician has with a patient regarding their ultimate outcome after a disease modifying treatment, as opposed to palliative treatments that may have only short-term benefits to the patient.”

And the major changes that surgeons should be aware of? Cost, time, and testing.

“The biggest changes that surgeons should be aware of in this updated Clinical Practice Guideline include the routine use of CTS-6 for the diagnosis of carpal tunnel syndrome,” explained Dr. Shapiro. “There is strong evidence that carpal tunnel syndrome can be diagnosed using CTS-6 in lieu of routine use of electrodiagnostic or ultrasonographic studies, which can save patients unnecessary testing, unnecessary appointments, time, pain, and out of pocket costs.”

“Further, when looking at long-term and durable outcomes, there was no strong evidence to support the use of corticosteroid or platelet rich plasma injections in modifying CTS. Other major changes include guidance on various treatment nuances that are important in a value-based care system that values high-quality and patient-centered care, including challenging the routine use of things like supervised therapy post-operatively, perioperative prophylactic antibiotics, and intravenous regional anesthesia.”

“The Clinical Practice Guideline includes multiple consensus-based recommendations including, for example:

1. routine pre-operative testing (e.g., labs, CXR [chest X-ray], EKG) is not indicated and,
2. when multiple amyloidosis risk factors are present, pathologic analysis of tenosynovium may be warranted. While the former is supported by evidence in cohorts of patients with common hand conditions (including those with carpal tunnel syndrome), there is a lack of evidence upon which to base these recommendations.

Finally, Dr. Shapiro told OTW, opportunities for future research are highlighted throughout the Clinical Practice Guidelines. These are gaps in the research [that] point researchers and investigators toward improving long-term outcomes and delivering more precise diagnostic and treatment options to promote equitable, high-quality, patient-centered care.