Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX.
Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX.
J Hand Surg Am. 2022 Aug;47(8):736-744. doi: 10.1016/j.jhsa.2022.04.007. Epub 2022 Jun 6.
The utility of electrodiagnostic tests (EDx) for patients with a high pretest probability of idiopathic median neuropathy at the carpal tunnel (IMNCT) based on characteristic symptoms and signs is debated. Decision-making and care strategies could be informed by a better understanding of factors associated with surgeon recommendations for electrodiagnostic testing.
Ninety-one upper-extremity surgeons participated in an online, survey-based experiment. Participants viewed 7 vignettes of patients with carpal tunnel syndrome, with the following factors randomized in each vignette: patient age, gender, magnitude of incapability, symptom intensity and the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results. We sought patient and surgeon factors associated with ordering EDx and surgeon-rated comfort with performing carpal tunnel release (CTR) without EDx.
Surgeons recommended EDx for over half of the patient vignettes, with notable variation (median, 57%; interquartile range, 14-100), and felt relatively neutral, on average, offering CTR without EDx. Twenty-six (29%) out of 91 surgeons ordered EDx for all patient scenarios, and 18 surgeons (20%) did not order testing for any scenario. A lower likelihood of EDx was associated with older age and positive provocative tests results. Greater surgeon comfort offering CTR without EDx was associated with older patients, the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results.
Upper-extremity surgeons are neutral regarding diagnosing IMNCT based on electrodiagnostic evidence of pathology and are relatively more comfortable offering surgery without EDx in older patients that present with key aspects of carpal tunnel syndrome. There is notable variation in care, with half of all surgeons always or never ordering EDx.
Future studies can investigate whether a treatment strategy offering surgery to patients with a high pretest probability of IMNCT and only using EDx in intermediate probability scenarios can limit use of testing without affecting patient health.
基于特征性症状和体征，对于术前正中神经腕管（IMNCT）可能性高的特发性正中神经病变患者，电诊断测试（EDx）的效用存在争议。通过更好地了解与外科医生推荐进行 EDx 测试相关的因素，决策和护理策略可以得到指导。
91 名上肢外科医生参与了一项在线基于调查的实验。参与者查看了 7 个腕管综合征患者的病例，每个病例中的随机因素包括：患者年龄、性别、能力丧失程度、症状强度和夜间症状、手掌外展无力以及阳性诱发试验结果。我们寻找与进行 EDx 相关的患者和外科医生因素，以及外科医生对无需 EDx 进行腕管松解术（CTR）的舒适度。
外科医生推荐对超过一半的患者病例进行 EDx，差异显著（中位数为 57%；四分位距为 14-100%），并且平均而言，对于无需 EDx 提供 CTR 感觉相对中立。26 名（29%）外科医生对所有患者情况都进行了 EDx 检查，18 名（20%）外科医生对任何情况都没有进行检查。较低的 EDx 检查可能性与年龄较大和阳性诱发试验结果相关。提供无需 EDx 进行 CTR 的外科医生舒适度更高与患者年龄较大、夜间症状、手掌外展无力和阳性诱发试验结果相关。
上肢外科医生对于根据 EDx 检查结果诊断 IMNCT 持中立态度，并且在出现腕管综合征关键方面的老年患者中，他们相对更愿意在不进行 EDx 的情况下提供手术。护理方面存在显著差异，一半的外科医生总是或从不进行 EDx 检查。
未来的研究可以调查是否有一种治疗策略，即对术前 IMNCT 可能性高的患者提供手术，仅在中等可能性情况下使用 EDx，可以限制测试的使用而不会影响患者健康。
