The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on: Management of Carpal Tunnel Syndrome

Graham, Brent MD, MSc, FRCSC; Peljovich, Allan E. MD, MPH; Afra, Robert MD; Cho, Mickey S. MD; Gray, Rob MD; Stephenson, John MD; Gurman, Andrew MD; MacDermid, Joy PhD; Mlady, Gary MD; Patel, Atul T. MD; Rempel, David MD, MPH; Rozental, Tamara D. MD; Salajegheh, Mohammad Kian MD; Keith, Michael Warren MD; Jevsevar, David S. MD, MBA; Shea, Kevin G. MD; Bozic, Kevin J. MD, MBA; Adams, Julie MD; Evans, Jay Mark MD; Lubahn, John MD; Ray, Wilson Zachary MD; Spinner, Robert MD; Thomson, Grant MD, MSc; Shaffer, William O. MD; Cummins, Deborah S. PhD; Murray, Jayson N. MA; Mohiuddin, Mukarram MPH; Mullen, Kyle MPH; Shores, Peter MPH; Woznica, Anne MLS; Linskey, Erica; Martinez, Yasseline; Sevarino, Kaitlyn MBA

Journal of Bone & Joint Surgery - American Volume: 19 October 2016 - Volume 98 - Issue 20 - p 1750–1754
doi: 10.2106/JBJS.16.00719
Evidence-Based Orthopaedics
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Introduction

The AAOS Evidence-Based Guideline on Management of Carpal Tunnel Syndrome (CTS) includes both diagnosis and treatment. This clinical practice guideline has been endorsed by the American Society for Surgery of the Hand (ASSH), the American College of Radiology (ACR), the American College of Surgeons (ACS), and the American Society of Plastic Surgeons (ASPS). This brief summary of the AAOS Clinical Practice Guideline contains a list of the recommendations and the rating of strength based on the quality of the supporting evidence. Discussion of how each recommendation was developed and the complete evidence report are contained in the full guideline at www.aaos.org/guidelines.

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Summary of Recommendations

OBSERVATION

Strong evidence supports that thenar atrophy is strongly associated with ruling in CTS but poorly associated with ruling out CTS.

Strength of Recommendation: Strong ★★★★

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PHYSICAL SIGNS

Strong evidence supports not using the Phalen test, Tinel sign, or upper limb neurodynamic/nerve test (ULNT) criterion A/B as independent physical examination maneuvers to diagnose CTS, because alone, each has a poor or weak association with ruling in or ruling out CTS.

Strength of Recommendation: Strong ★★★★

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MANEUVERS

Moderate evidence supports not using the following as independent physical examination maneuvers to diagnose CTS, because alone, each has a poor or weak association with ruling in or ruling out CTS:

* Carpal compression test

* Reverse Phalen test

* Thenar weakness or thumb abduction weakness or abductor pollicis brevis manual muscle testing

* 2-point discrimination

* Semmes-Weinstein monofilament test

* CTS-relief maneuver (CTS-RM)

* Pin-prick sensory deficit, thumb or index or middle finger

* ULNT criterion C

* Tethered median nerve stress test

* Vibration perception—tuning fork

* Scratch collapse test

* Luthy sign

* Pinwheel test

Strength of Recommendation: Moderate ★★★☆

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HISTORY INTERVIEW TOPICS

Moderate evidence supports not using the following as independent history interview topics to diagnose CTS, because alone, each has a poor or weak association with ruling in or ruling out CTS:

* Sex/gender

* Ethnicity

* Bilateral symptoms

* Diabetes mellitus

* Worsening symptoms at night

* Duration of symptoms

* Patient localization of symptoms

* Hand dominance

* Symptomatic limb

* Age

* BMI

Strength of Recommendation: Moderate ★★★☆

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PATIENT-REPORTED NUMBNESS OR PAIN

Limited evidence supports that patients who do not report frequent numbness or pain might not have CTS.

Strength of Recommendation: Limited ★★☆☆

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HAND-HELD NERVE-CONDUCTION STUDY (NCS) DEVICE

Limited evidence supports that a hand-held nerve conduction study (NCS) device might be used for the diagnosis of CTS.

Strength of Recommendation: Limited ★★☆☆

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MRI

Moderate evidence supports not routinely using MRI for the diagnosis of CTS.

Strength of Recommendation: Moderate ★★★☆

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DIAGNOSTIC ULTRASOUND

Limited evidence supports not routinely using ultrasound for the diagnosis of CTS.

Strength of Recommendation: Limited ★★☆☆

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DIAGNOSTIC SCALES

Moderate evidence supports that diagnostic questionnaires and/or electrodiagnostic studies could be used to aid the diagnosis of CTS.

Strength of Recommendation: Moderate ★★★☆

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INCREASED RISK OF CTS

A. Strong evidence supports that BMI and high hand/wrist repetition rate are associated with the increased risk of developing CTS.

Strength of Recommendation: Strong ★★★★

B. Moderate evidence supports that the following factors are associated with the increased risk of developing CTS:

* Perimenopause

* Wrist ratio/index

* Rheumatoid arthritis

* Psychosocial factors

* Distal upper-extremity tendinopathies

* Gardening

* ACGIH (American Conference for Government Industrial Hygienists) hand activity level at or above threshold

* Assembly line work

* Computer work

* Vibration

* Tendonitis

* Workplace forceful grip/exertion

Strength of Recommendation: Moderate ★★★☆

C. Limited evidence supports that the following factors are associated with the increased risk of developing CTS:

* Dialysis

* Fibromyalgia

* Varicosis

* Distal radius fracture

Strength of Recommendation: Limited ★★☆☆

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DECREASED RISK OF CTS

Moderate evidence supports that physical activity/exercise is associated with the decreased risk of developing CTS.

Strength of Recommendation: Moderate ★★★☆

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FACTORS SHOWING NO ASSOCIATED RISK OF CTS

A. Moderate evidence supports that the use of oral contraception and female hormone replacement therapy (HRT) are not associated with increased or decreased risk of developing CTS.

Strength of Recommendation: Moderate ★★★☆

B. Limited evidence supports that race/ethnicity and female education level are not associated with increased or decreased risk of developing CTS.

Strength of Recommendation: Limited ★★☆☆

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FACTORS SHOWING CONFLICTING RISK OF CTS

Limited evidence supports that the following factors have conflicting results regarding the development of CTS:

* Diabetes

* Age

* Gender/sex

* Genetics

* Comorbid drug use

* Smoking

* Wrist bending

* Workplace

Strength of Recommendation: Limited ★★☆☆

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IMMOBILIZATION

Strong evidence supports that the use of immobilization (brace/splint/orthosis) should improve patient-reported outcomes.

Strength of Recommendation: Strong ★★★★

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STEROID INJECTIONS

Strong evidence supports that the use of steroid (methylprednisolone) injection should improve patient-reported outcomes.

Strength of Recommendation: Strong ★★★★

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MAGNET THERAPY

Strong evidence supports not using magnet therapy for the treatment of CTS.

Strength of Recommendation: Strong ★★★★

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ORAL TREATMENTS

Moderate evidence supports no benefit of oral treatments (diuretic, gabapentin, astaxanthin capsules, NSAIDs, or pyridoxine) compared to placebo.

Strength of Recommendation: Moderate ★★★☆

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ORAL STEROIDS

Moderate evidence supports that oral steroids could improve patient-reported outcomes as compared to placebo.

Strength of Recommendation: Moderate ★★★☆

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KETOPROFEN PHONOPHORESIS

Moderate evidence supports that ketoprofen phonophoresis could improve reduction in pain compared to placebo.

Strength of Recommendation: Moderate ★★★☆

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THERAPEUTIC ULTRASOUND

Limited evidence supports that therapeutic ultrasound might be effective compared to placebo.

Strength of Recommendation: Limited ★★☆☆

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LASER THERAPY

Limited evidence supports that laser therapy might be effective compared to placebo.

Strength of Recommendation: Limited ★★☆☆

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SURGICAL RELEASE LOCATION

Strong evidence supports that surgical release of the transverse carpal ligament should relieve symptoms and improve function.

Strength of Recommendation: Strong ★★★★

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SURGICAL RELEASE PROCEDURE

Limited evidence supports that if surgery is chosen, a practitioner might consider using endoscopic carpal tunnel release based on possible short-term benefits.

Strength of Recommendation: Limited ★★☆☆

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SURGICAL VERSUS NONOPERATIVE

Strong evidence supports that surgical treatment of CTS should have a greater treatment benefit at 6 and 12 months as compared to splinting, NSAIDs/therapy, and a single steroid injection.

Strength of Recommendation: Strong ★★★★

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ADJUNCTIVE TECHNIQUES

Moderate evidence supports that there is no benefit to routine inclusion of the following adjunctive techniques: epineurotomy, neurolysis, flexor tenosynovectomy, and lengthening/reconstruction of the flexor retinaculum (transverse carpal ligament).

Strength of Recommendation: Moderate ★★★☆

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BILATERAL VERSUS STAGED CARPAL TUNNEL RELEASE

Limited evidence supports that simultaneous bilateral or staged endoscopic carpal tunnel release might be performed based on patient and surgeon preference. No evidence meeting the inclusion criteria was found addressing bilateral simultaneous open carpal tunnel release.

Strength of Recommendation: Limited ★★☆☆

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LOCAL VERSUS INTRAVENOUS REGIONAL ANESTHESIA

Limited evidence supports the use of local anesthesia rather than intravenous regional anesthesia (Bier block) because it might offer longer pain relief after carpal tunnel release; no evidence meeting our inclusion criteria was found comparing general anesthesia to either regional or local anesthesia for carpal tunnel surgery.

Strength of Recommendation: Limited ★★☆☆

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BUFFERED VERSUS PLAIN LIDOCAINE

Moderate evidence supports the use of buffered lidocaine rather than plain lidocaine for local anesthesia because it could result in less injection pain.

Strength of Recommendation: Moderate ★★★☆

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ASPIRIN USE

Limited evidence supports that the patient might continue the use of aspirin perioperatively; no evidence meeting our inclusion criteria addressed other anticoagulants.

Strength of Recommendation: Limited ★★☆☆

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PREOPERATIVE ANTIBIOTICS

Limited evidence supports that there is no benefit for routine use of prophylactic antibiotics prior to carpal tunnel release because there is no demonstrated reduction in postoperative surgical site infection.

Strength of Recommendation: Limited ★★☆☆

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SUPERVISED VERSUS HOME THERAPY

Moderate evidence supports no additional benefit to routine supervised therapy over home programs in the immediate postoperative period. No evidence meeting the inclusion criteria was found comparing the potential benefit of exercise versus no exercise after surgery.

Strength of Recommendation: Moderate ★★★☆

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POSTOPERATIVE IMMOBILIZATION

Strong evidence supports no benefit to routine postoperative immobilization after carpal tunnel release.

Strength of Recommendation: Strong ★★★★

Disclosure: The disclosure information for the Work Group members and the AAOS staff on this guideline are found in Appendix IX (page 775) of the guideline document at www.aaos.org/guidelines.

Disclaimer: This Clinical Practice Guideline was developed by an AAOS multidisciplinary volunteer Work Group based on a systematic review of the current scientific and clinical information and accepted approaches to treatment and/or diagnosis. This Clinical Practice Guideline is not intended to be a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s clinical circumstances.

The complete AAOS guideline is available at www.aaos.org/guidelines.

Copyright 2016 by The Journal of Bone and Joint Surgery, Incorporated