National trends in the initial diagnosis and management of carpal tunnel syndrome: results from the ELECTS (ELEctrophysiology in Carpal Tunnel Syndrome) study

Abstract

Introduction: The optimal role of nerve conduction studies (NCS) in management of carpal tunnel syndrome (CTS) is unclear, with no standardised guidance. This study aimed to identify variation in practice in the initial diagnosis of patients with suspected CTS, alongside evaluating how NCS findings influence clinical decision making.

Methods: A national multicentre collaborative survey was conducted in 2021. All centres providing surgery for CTS were invited to participate, primarily via social media. All middle-senior grade orthopaedic/plastic surgeons and advanced care practitioners that regularly manage new referrals for suspected CTS were eligible to respond. Local representatives at each participating site submitted their responses to a central team who collated and analysed the results.

Results: A total of 137 healthcare professionals responded from 18 UK NHS Trusts. Of these 137, 124 (91%) reported not employing any validated clinical questionnaires in their routine practice, preferring to rely on clinical diagnosis and/or NCS if available, whereas 84 (61%) utilised NCS to aid diagnosis, with significant differences among professionals with differing experience (p < 0.01). The most common methods for determining the severity of CTS were history, examination and NCS. In symptomatic CTS with confirmatory NCS, over 50% of clinicians would choose surgical decompression as their first-line intervention. In cases of either negative NCS or atypical presentation, 37% and 51%, respectively, would consider conservative management (e.g. splintage) or steroid injection first line.

Conclusions: With growing waiting lists for NCS and surgery, national consensus guidelines should be developed to support decision making, while maximising efficient utilisation of increasingly constrained resources.

Keywords: Carpal tunnel syndrome; Electrophysiology; Median neuropathy; Nerve conduction studies.

Figure 1

Use of clinical questionnaires in the diagnosis of CTS. Most (89%) do not use validated clinical questionnaires. Only 11% routinely used clinical questionnaires and, of these, the frequency of use varied from <10% to >90% cases.

Figure 2

Use of NCS in the diagnosis of CTS. Most do use NCS for newly suspected CTS, but frequency of ordering CTS varies. Of those who routinely used NCS, 48 requested the study after clinic whereas 9 requested before first clinic. Chi-squared analysis found that specialty registrars and middle grade doctors were more likely to use NCS routinely, whereas hand surgeons (both plastics and orthopaedics) used NCS more selectively (p < 0.01).

Figure 3

Preferred management in four hypothetical clinical scenarios In both scenarios 1 and 2 (clinically and NCS positive for primary CTS), most would advocate CTD first line. In scenarios 3 and 4 (clinical findings and NCS findings inconsistent), most propose more conservative initial management. No statistical correlation between clinical role/grade and management option of each scenario.