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Indications for Performing Carpal Tunnel Surgery: Clinical Quality Measures

Maggard, Melinda A. M.D., M.S.H.S.; Harness, Neil G. M.D.; Chang, Walter T. M.D.; Parikh, Janak A. M.D.; Asch, Steven M. M.D., M.P.H.; Nuckols, Teryl K. M.D., M.S.H.S.on behalf of the Carpal Tunnel Quality Group

Plastic and Reconstructive Surgery: July 2010 - Volume 126 - Issue 1 - p 169-179
doi: 10.1097/PRS.0b013e3181da8685
Hand/Peripheral Nerve: Outcomes Article

Background: Rates of carpal tunnel surgery vary for unclear reasons. In this study, the authors developed measures determining when surgery is necessary (benefits exceed risks), inappropriate (risks outweigh benefits), or optional.

Methods: Measures were developed using a modified-Delphi panel. Clinical scenarios were defined incorporating symptom severity, symptom duration, clinical probability of carpal tunnel syndrome, electrodiagnostic testing, and nonoperative treatment response. A multidisciplinary panel of 11 carpal tunnel syndrome experts rated appropriateness of surgery for each scenario on a scale ranging from 1 to 9 scale (7 to 9, surgery is necessary; 1 to 3, surgery is inappropriate).

Results: Of 90 scenarios (36 for mild, 36 for moderate, and 18 for severe symptoms), panelists judged carpal tunnel surgery as necessary for 16, inappropriate for 37, and optional for 37 scenarios. For mild symptoms, surgery is generally necessary when clinical probability of carpal tunnel syndrome is high, there is a positive electrodiagnostic test, and there has been unsuccessful nonoperative treatment. For moderate symptoms, surgery is generally necessary with a positive electrodiagnostic test involving two or more of the following: high clinical probability, unsuccessful nonoperative treatment, and symptoms lasting longer than 12 months. Surgery is generally inappropriate for mild to moderate symptoms involving two or more of the following: low clinical probability, no electrodiagnostic confirmation, and nonoperative treatment not attempted. For severe symptoms, surgery is generally necessary with a positive electrodiagnostic test or unsuccessful nonoperative treatment.

Conclusions: These are the first formal measures assessing appropriateness of carpal tunnel surgery. Applying these measures can identify underuse (failure to provide necessary care) and overuse (providing inappropriate care), giving insight into variations in receipt of this procedure.


Los Angeles, Sylmar, Fontana, Yorba Linda, and Santa Monica, Calif.

From the Department of Surgery and the Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA; Olive View–UCLA; the Department of Hand Surgery, Kaiser Permanente, Fontana Medical Center; the Department of Hand Surgery, Kaiser Permanente, Yorba Linda Medical Offices; the RAND Corporation; and the Veterans Affairs Greater Los Angeles Healthcare System.

Received for publication April 28, 2009; accepted January 8, 2010.

The members of the Carpal Tunnel Quality Group are listed in an Appendix at the end of this article.

Disclosure: This project was supported by equal contributions from the California Commission on Health and Safety and Workers' Compensation, a state-sponsored joint labor/management body charged with overseeing the health and safety and workers' compensation systems in California and recommending administrative or legislative modifications to improve their operation; and from Zenith Insurance, a workers' compensation insurance company based in Woodland Hills, California. The funders played no role in the design, execution, or reporting of the study.

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Melinda A. Maggard, M.D., M.S.H.S., Department of Surgery, David Geffen School of Medicine at UCLA, CHS 72-215, 10833 Le Conte Avenue, Los Angeles, Calif. 90095,

©2010American Society of Plastic Surgeons