Lane Lewis B, Starecki Mikael, Olson Ashley, Kohn Nina
Departments of Orthopaedic Surgery, North Shore University Hospital, Manhasset, NY; Long Island Jewish Medical Center, New Hyde Park, NY; Biostatistics Unit, Feinstein Institute for Medical Research, North Shore-LIJ Health System, Manhasset, NY.
Departments of Orthopaedic Surgery, North Shore University Hospital, Manhasset, NY; Long Island Jewish Medical Center, New Hyde Park, NY; Biostatistics Unit, Feinstein Institute for Medical Research, North Shore-LIJ Health System, Manhasset, NY.
J Hand Surg Am. 2014 Nov;39(11):2181-87.e4. doi: 10.1016/j.jhsa.2014.07.019. Epub 2014 Sep 13.
In 2007 and 2009, the American Academy of Orthopaedic Surgeons released Clinical Practice Guidelines (CPG) for diagnosis and treatment of carpal tunnel syndrome (CTS) based upon review of the literature. The lack of consistently high-level evidence resulted in several recommendations, some strongly supported, some weakly supported, and others controversial. We postulated that a survey of American Society for Surgery of the Hand (ASSH) members would provide insight into practice patterns among hand surgeons treating CTS and demonstrate the extent to which the CPG influenced practice behavior.
A multiple-choice questionnaire including detailed commonly observed clinical scenarios was developed, pre-tested, and approved by our institutional review board and the ASSH Web site committee chair. An anonymous electronic survey was emailed to ASSH members.
Surveys were sent to 2,650 eligible ASSH members, and 27% responded. Seventy-two percent would advise a patient to have carpal tunnel release (CTR) if the patient had both classic history/examination of CTS and complete relief following cortisone injection. Forty-seven percent responded that in this scenario electrodiagnostic testing (EDX) is rarely or never necessary to recommend CTR. Seventy-nine percent of respondents were at least slightly more likely to order EDX based on CPG recommendations. Of these respondents, 57% replied that this was because of potential medicolegal ramifications.
Although the CPG recommended EDX before surgery, and although most responding ASSH members use EDX to advise CTR, a majority answered that a supporting history and physical examination alone can be sufficient to recommend surgery, that a positive response to a cortisone injection can be sufficient indication for CTR, that EDX is not necessary in all cases of CTS, and that they would perform CTR in face of normal EDX if cortisone temporarily resolved symptoms. Among respondents more likely to order EDX based on the CPG, 57% answered that it was in some circumstances due to potential medicolegal ramifications.
TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis III.
2007年和2009年，美国骨科医师学会基于文献综述发布了关于腕管综合征（CTS）诊断和治疗的临床实践指南（CPG）。由于缺乏始终如一的高水平证据，导致了若干建议，有些得到有力支持，有些支持力度较弱，还有些存在争议。我们推测，对手外科医师协会（ASSH）成员进行调查将有助于深入了解治疗CTS的手外科医生的实践模式，并展示CPG对实践行为的影响程度。
编制了一份包含详细常见临床情景的多项选择题问卷，经过预测试，并得到我们机构审查委员会和ASSH网站委员会主席的批准。向ASSH成员发送了一份匿名电子调查问卷。
向2650名符合条件的ASSH成员发送了调查问卷，27%的人进行了回复。如果患者既有典型的CTS病史/检查结果，又在注射皮质醇后症状完全缓解，72%的人会建议患者进行腕管松解术（CTR）。47%的人回答，在这种情况下，很少或根本不需要进行电诊断测试（EDX）来推荐CTR。79%的受访者至少稍微更倾向于根据CPG建议进行EDX检查。在这些受访者中，57%的人回答这是因为潜在的法医学后果。
尽管CPG建议在手术前进行EDX检查，并且尽管大多数回复的ASSH成员使用EDX来指导CTR，但大多数人回答仅靠支持性的病史和体格检查就足以推荐手术，对皮质醇注射的阳性反应足以作为CTR的指征，并非所有CTS病例都需要进行EDX检查，如果皮质醇暂时缓解了症状，即使EDX结果正常，他们也会进行CTR。在更倾向于根据CPG进行EDX检查的受访者中，57%的人回答在某些情况下是由于潜在的法医学后果。
研究类型/证据水平：经济与决策分析III。
