Appropriate Use Criteria for Carpal Tunnel Syndrome

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Leon S. Benson, MD.

Appropriate Use Criteria (AUC) are suggested treatment algorithms for a variety of common orthopaedic conditions, published by the American Academy of Orthopaedic Surgeons.
These algorithms follow logically from the AAOS’s earlier work in publishing Clinical Practice Guidelines, and the methodology behind development of Appropriate Use Criteria is available in great detail on the AAOS website.

It is clear that the recent creation of Appropriate Use Criteria for carpal tunnel syndrome (CTS), like the other AUC algorithms, was very thoughtful and included the input of numerous experts. It is also clear that these criteria reflect an enormous amount of time and energy on the part of the AUC workgroup in attempting to reflect the best available evidence in managing carpal tunnel syndrome, while also allowing reasonable latitude in judgment on the part of the treating clinician.

The CTS AUC, like all AAOS AUC, are available as a downloadable application for virtually any computer or mobile platform. Using the AUC app is simple. The clinician selects items that correspond to elements of the patient’s history, physical examination, and testing/imaging findings, and then the AUC app categorizes various treatment (and/or workup) options as “appropriate,” “may be appropriate,” or “rarely appropriate.”

However, a few quirks of the CTS AUC may annoy some experienced clinicians. For example, in grading the patient’s history, the app requires that the clinician use either the Katz Hand Symptom Diagram or the CTS-6 history survey. I doubt that most seasoned hand surgeons routinely use these history tools unless their patient is enrolled in a research study. Additionally, the CTS-6 history survey lists “nocturnal numbness” as a choice; carpal tunnel patients typically report nocturnal pain that awakens them from sleep, not numbness (which is usually noticed upon awakening in the morning). In fact, nocturnal pain is probably the most reliable historical detail in confirming carpal tunnel syndrome. The CTS-6 criteria also give considerable weight to the presence of a positive Phalen’s test and Tinel’s sign even though these findings are commonly present in patients who have no pathology. The absence of these physical findings in patients who are suspected of carpal tunnel syndrome is probably more meaningful.

For the most part, though, the CTS AUC get a lot right about currently accepted treatment pathways for carpal tunnel syndrome. Playing around with the app, I was unable to create a combination of history, physical findings, and test data that produced treatment options with which I couldn’t agree. Furthermore, the AUC permit enough latitude in treatment recommendations to encompass the personal preferences of the vast majority of hand surgeons.

But perhaps the most compelling question is — why do we need an AUC app in the first place?  Doctors crave autonomy for many reasons, not the least of which are the extreme time commitment and intellectual demands of medical training, including residency and fellowship. Furthermore, orthopaedic judgment is refined through years of practical experience accrued over the course of a career. How can that be simulated with a simplified decision tree that boils everything down to a handful of categories?  And few fellowship-trained hand surgeons will immediately like the idea of an amorphous body of “experts” coming up with an iPhone app to tell them how to treat carpal tunnel syndrome.

However, there is another, critically important theme to the AUC story.  Our colleagues who contribute their expertise to the AAOS AUC projects are actually providing a huge service to orthopaedic patients nationwide.  As health-care delivery in the United States evolves, third-party payors and policy decision-makers are demanding that treatments be evidence based and consistent with expert consensus of “best practices.”  If doctors themselves do not weigh in on this topic, stakeholders who are neither patients nor providers will make up the rules. Most certainly, that would be less optimal for patients than physician experts helping craft treatment parameters, even if the parameters so created are not perfect or applicable to every imaginable clinical scenario.

With this perspective in mind, the CTS AUC have achieved reasonable goals, and they support most of the commonly recommended treatment approaches to managing carpal tunnel syndrome.  More importantly, the AUC-development process allows the community of orthopaedic specialists to have a seat at the table when value-based medicine is demanded, as it should be, by both our patients and policy-makers.

Although my pride might be a little bruised when I imagine practicing medicine by checking off boxes on a mobile app, I can handle it if it strengthens the identity of orthopaedic surgeons as leaders in doing what’s best for our patients.

Leon S. Benson, MD is chief of the Division of Hand Surgery at NorthShore University Healthsystem, professor of clinical orthopaedic surgery at the University of Chicago Pritzker School of Medicine, and a hand surgeon at the Illinois Bone and Joint Institute. He is also a JBJS associate editor.