The American Academy of Orthopaedic Surgeons (AAOS), has issued the first update in eight years to the Clinical Practice Guideline(CPG) for Management of Carpal Tunnel Syndrome (CTS). Interestingly, the guideline notes no strong evidence for an association between high keyboard use and CTS.
CTS is the most common compressive neuropathy affecting the upper extremity. Symptoms like pain, numbness and tingling in the hand and forearm can lead to morbidity and lost productivity.
“The CPG was organised to cover workup, treatment and postoperative care of CTS and highlights areas where certain patients can avoid some debatable preoperative treatments (e.g., corticosteroid injections), preoperative tests and postoperative therapies based on the evidence in this guideline,” said Robin Kamal, MD, FAAOS, co-chair of the guideline development group.
Diagnosis Updated recommendations are that CTS-6, an evaluation tool that accounts for symptoms and disease history can be used in lieu of the routine use of ultrasonography or a nerve conduction velocity test (NCV) and electromyography (EMG) which can be painful and expensive. Additionally, moderate evidence suggests that MRI and Upper Limb Neurodynamic testing should not be used to diagnose CTS.
Treatment
The CPG supports the notion that both mini-open and endoscopic carpal tunnel release provide similar long-term outcomes, and notes the following recommendations for treatment:
• Platelet-rich plasma (PRP) injections – a new addition to the CPG – and corticosteroid injections both demonstrated a lack of long-term benefits in the non-operative treatment of CTS.
• Strong evidence showed local anaesthetic alone can be used for carpal tunnel release.
• Limited evidence suggests that carpal tunnel release may be safely conducted in the office setting. Studies consistently demonstrated no increased risk of complications with higher ratings of patient experience and satisfaction compared with surgical release in the operating room.
Post-op care
The guideline also includes the following recommendations and option (guidance formulated with either low-quality evidence, no evidence or conflicting evidence) after surgical treatment:
• Moderate evidence suggests postoperative supervised therapy should not be routinely prescribed after carpal tunnel release.
• Strong evidence suggests non-steroidal anti-inflammatory drugs and/or acetaminophen should be used after carpal tunnel release for postoperative pain management.
• Limited evidence suggests perioperative prophylactic antibiotics are not indicated for the prevention of infection after carpal tunnel release.
Additionally, the guideline notes no evidence strongly supports the association between high keyboard use and CTS.
“The recommendations highlight areas intended for shared decision-making between patients and their physicians and are not meant to be used for insurer determinations,” said Kamal. “It’s important for patients to understand the risks, benefits, and costs associated with care in the preoperative (testing), intraoperative (anaesthesia) and postoperative (therapy) phases of surgical care.”
Development of this CPG was a collaborative effort between representatives from the American Society for Surgery of the Hand, the American Association for Hand Surgery, the American College of Occupational and Environmental Medicine, the American Society of Hand Therapists, the American College of Radiology, and the American Academy of Physical Medicine and Rehabilitation.
CPGs are not meant to be stand-alone documents but rather serve as a point of reference and educational tool for orthopaedic surgeons and healthcare professionals managing patients presenting with complaints which may be attributable to CTS.
Carpal Tunnel update guidelines
AAOS article – Carpal Tunnel Syndrome: AAOS Updates Clinical Practice Guideline (Open access)
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