The American Academy of Orthopaedic Surgeons (AAOS) has updated its Clinical Practice Guideline (CPG) for carpal tunnel syndrome (CTS).

Replacing the 2016 edition, AAOS devised the update to address the diagnosis and treatment of adult patients (18 years and older) complaining of CTS symptoms. The updated guideline is streamlined to focus on the long-term benefits of CTS treatment.
 
“While the 2016 guideline covered several recommendations for the short-term effects of CTS treatment, our workgroup chose to focus on long-term patient outcomes as shifts in healthcare require a focus on cost-effective, high-quality, and patient-centered care,” said Lauren Shapiro, M.D., co-chair of the guideline development group. “This update provides physicians and patients with clear recommendations to optimize outcomes while minimizing unnecessary interventions.”
 
CTS is the most common compressive neuropathy affecting the upper extremity. Symptoms such as pain, numbness and tingling in the hand and forearm can lead to morbidity and lost productivity. The National Institutes of Health estimates CTS accounts for $2.7 billion to $4.8 billion annually withIn the U.S. Medicare patient population.
 
“The CPG was organized 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 cited in this guideline,” said Robin Kamal, M.D., co-chair of the guideline development group.
 
CTS Diagnosis
The guideline updated the 2016 recommendation to include a strong recommendation on CTS diagnosis, noting that CTS-6, an evaluation tool accounting for symptoms and disease history, can be used to diagnose CTS. Strong evidence shows CTS-6 can be used instead 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 for treating the condition, and notes the following recommendations for CTS treatment:

• Neither platelet-rich plasma injections—a new CPG addition—nor corticosteroid injections show any long-term benefits in nonoperative CTS treatment.
• Strong evidence shows that local anesthetic 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 there is no increased risk of complications with higher ratings of patient experience and satisfaction when compared to surgical release in the operating room.

 
Postoperative Care
The guideline also includes the following recommendations and option (guidance formulated with either low-quality evidence, no evidence or conflicting evidence) after surgery:

• Moderate evidence suggests postoperative supervised therapy should not be routinely prescribed after carpal tunnel release.
• Strong evidence suggests that 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 preventing surgical site infection after carpal tunnel release.
   

Additionally, in the absence of reliable evidence, the guideline notes there is no evidence to strongly support an association between high keyboard use and CTS.
 
“The recommendations in this CPG highlight areas which are intended for shared decision-making between patients and their physicians and are not meant to be used for insurer determinations,” Kamal stated. “It’s important for patients to understand the risks, benefits, and costs associated with care in the preoperative (testing), intraoperative (anesthesia) and postoperative (therapy) phases of surgical care. As we continue research on the quality, cost, and patient-centeredness of various treatment approaches, our patients and profession will benefit.”
 
Developing the 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.
 
The full Clinical Practice Guideline for the Management of Carpal Tunnel Syndrome is intended for reference by orthopedic surgeons and other physicians, and available through AAOS’ OrthoGuidelines website and free mobile app. 
 
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS advances musculoskeletal health by providing comprehensive education to help orthopedic surgeons and allied health professionals best treat patients. The AAOS is the source for information on bone and joint conditions, treatments, and related musculoskeletal healthcare issues; and it leads the healthcare discussion on advancing quality.