Good morning. It's nice to see everybody here for the MOC on carpal tunnel surgery. The meeting's going so nicely so far, and we're going to be starting your day for you. Hopefully it'll be a good one. I'll be starting. My name's Loree Callianon. I helped organize, and I was fortunate enough to get some of my wonderful colleagues to share in this discussion. Don Lalonde, Amy Moore, and Christina Ward. We'll all be covering additional individual sections about the analysis of carpal tunnel, performance of the surgery, analysis of outcomes, and then at the end leave plenty of room for questions. So I'll be covering history, physical, and adjunctive testing. I have no financial disclosures, and I won't be discussing any off-label medications in my talk this morning. So today I'm hoping that you'll learn to remember the basic principles of history taking, to rule in or rule out the diagnosis of carpal tunnel syndrome, to consistently examine the patient in the upper extremity to most effectively rule in or rule out your diagnosis, and to choose appropriately any adjunctive test to confirm your diagnosis. As we're all very well aware, carpal tunnel syndrome is the most common compressive neuropathy, and its prevalence is anywhere between 1.5 and 4.9 percent in the United States, with an incidence, therefore, of four cases per 1,000 person years. In the United States alone, we're doing now more than 500,000 carpal tunnel releases a year. So this is something that's extraordinarily common, is being done in multiple settings by multiple different types of surgeons. One of the favorite articles that I love to quote and I've loved to read since I was a medical student was by Willis Croft et al. from the University of Michigan, probably around the mid-'80s. Greater than 90 percent of diagnoses can be based on chief complaint and history alone. And I think some of the unhappiest patients that I meet are people who were never listened to. And I see this in all areas, not just carpal tunnel surgery. But you walk in, and within a minute, the patient will tell you the diagnosis. In the United States, we give people 22 seconds to talk. And if left to their own devices, they will stop talking at about 30 seconds. In Europe, surgeons and physicians would give patients a little bit more time, you know, just when will they finally run out of steam and tell you their diagnosis. And that's about two minutes. So no matter what we're saying and how we're doing our practices, let the person talk, and they will tell you the diagnosis. I think it's also important not to rely on other people's diagnosis. I get people coming in with a diagnosis of carpal tunnel syndrome, and they have nothing related to carpal tunnel. They've got trigger fingers, basilar arthritis. It's nothing that's wrong with the person who sent them to you. It's just they have a limited differential. Or they may say, my hand hurts, and the person who's scheduling them says, must be carpal tunnel, and they put that down. So please start from the beginning, let your person talk, and don't believe anything that you say or, you know, until you have determined that it's true. It's important to keep your distractors in mind when you're examining a patient. Workers' comp, legal issues, and the fear of diagnosis of carpal tunnel. I found this to be one of the most fascinating things in my 16 years in practice. People will say, it's almost like cancer. I don't have carpal tunnel, do I? Because they all have a relative, a friend, whose hand was ruined by carpal tunnel surgery. And that's, you know, it seems to me very sad, you know, that this has gone on, but it has become this disease that is way disproportionate to, I think, its effect and its management. So when you're looking at your history, things that will help you rule in are night waking, the flick sign where they say, I do this, I shake my hand, and it makes it feel better. Improvement with a night splint, and frequently they will have seen a family doctor or a primary care internist, hand therapist before they see you. And it's always nice to ask, have you been treated in any way? It should be involved in the median distribution, although if it's been going on for a while, it's not uncommon to also have the person say, it's my whole hand. They may be dropping things. They can have shoulder and upper extremity pain elsewhere. I've had several people who have had a chief complaint of shoulder pain. Their orthopedic surgeon has managed their shoulder pain, has not found anything that's intrinsic, and then one day they happen to mention, oh, and my fingers are numb, and they get in to see me, and that is the cause that you can have radiating pain. They will often complain of swelling, color changes, and temperature changes. And you may not see any of those, but it may be how they feel on the inside. And nerves are weird. And something I tell all my patients, it's something I tell all of my trainees. And I would really love to do a study with a semantician or a linguist or something, because it seems like when people have nerve issues and they come in and tell you things like, they use a lot of adjectives. I've got elves in there that are dancing around with football cleats. It's crushing. It's burning. It's hot water dripping inside of me. Nerve issues seem to bring out the adjectives in people. I know that we've been sometimes told that nerve compressions aren't painful, but if your person has only a limited vocabulary, they are not going to tell you the words that we know as physicians. And so it's really important not to rule things out because they're using words that you're not accustomed to. You want to do things like ruling out neck pain. They may have carpal tunnel, but if they have neck pain, they are not getting surgery from me until we have managed their neck. You want to look for things like motor greater than sensory, where you may find ALS. It may make another rare, weird diagnosis. Things like a failed prior carpal tunnel. Did the person who did their carpal tunnel before you actually fail to completely release the ligament, or do they have something else going on, like a pronator syndrome or a neck pathology? You want to ask if they have dorsal pain or numbness, because that's pretty much not it. They can have anything volarly, but nothing dorsally. And a complaint of joint stiffness as their primary complaint, or joint pain, because if you have bad basilar arthritis, it can irritate the carpal tunnel without having carpal tunnel syndrome. Way, way back in medical school, we learned the inspect, palpate, percuss, auscultate, you know, for every part of the body. And it's the same for the hand. So you want to look at both of them. You want to see, do they have an obvious wasting? Do they have something that's an obvious thenar atrophy? Do they have a CMC step-off? Palpating, actually touch the patient. Tenels would be your percussion. And then listen to the ouch, or the patient conversation when you're doing the exam. Look at their skin color and temperature. In darker skin patients, you can sometimes actually see skin discoloration in the path of the median nerve. I've tried to take photographs of it without success, but I've had several darker skin patients who have had a carpal tunnel release on one side, and their skin color normalizes. And on the carpal tunnel compressed side, it's darker. And I can't explain that unless it's something related to vascular supply or perhaps lymphatics. You want to start at the top to rule out other diagnoses. And so every carpal tunnel evaluation should start with C-spine compression in neutral, inflection, and an extension. And if they start complaining of pain, you really need to focus on that. I send people off to physical therapy first, but, of course, do the remainder of your exam. You want to check your tenels at your brachial plexus, elbow, and wrist. And you can't do some homeopathic little tapping. One of my favorite professors when I was a hand fellow, a man named Greg Degnan from Virginia, said, no, you have to whack them. And as long as you know that they don't have an actual injury at some spot, a tenel should really be pretty firm, not some little, you know, think, oh, are you fine there. Phalans and Durkins are also reasonable, and scratch collapse. If you haven't done the scratch collapse or seen it, I would recommend reading about this. This was Susan McKinnon and Christine Novak. And I find that the combination of these leads to your diagnosis because it's a syndrome. They aren't accustomed in surgery so much as the internists are in managing syndromic issues. They are very, very comfortable in rheumatology and internal medicine to say, all right, you have seven out of 11 of the symptoms and findings, and so you have scleroderma. You have rheumatoid arthritis. And we're less comfortable doing that. But you have to do that in this situation. And so when you look at all of the data, there is no one gold standard for a diagnosis. It's a group of things that you find that increase your diagnostic probability or decrease it. So I do all of these things, but I don't count specifically on one of them. Light touch and two-point discrimination. I've not been incredibly, you know, meticulous about diagnosing how much two-point discrimination when I'm using the other ones. I generally do, does this feel the same as the other one? There's something called the 10-10 test that was recommended for a while, and it involves touching the fingertip and the upper lip because apparently the nerve innervation is the same on both areas. I can't get people to understand this. I can't get any patient in multiple states to understand what this means, because they'll say, all right, well, your upper lip, that's normal, so we'll call that a 10. And if you couldn't feel your finger, then that would be a zero. So then I do, okay, so this is a 10. What's this? And they're like, I just don't find it to be helpful in my hands in Minnesota, Michigan, Virginia, Ohio, or North Carolina. So I don't know if you guys have been luckier in some other place than I. When you look at sensitivity and your specificity of individual provocative maneuvers, you find that there's a huge range in the literature. None of them are perfect. And it varies on is this a person that is having just a screening test in a random population, or is your diagnostic probability improved by being sent to a hand surgeon? And so you have to look at the literature to try to see which patient population is being tested to see how sensitive and specific your tests are. If you are seeing as a hand surgeon these patients, well, then they probably have been vetted in some way before you, and so your diagnostic probability is higher when you're using these tests. And they all are reasonably moderately high with your sensitivity, specificity, and especially negative predictive value. So if you don't have them, you probably don't have the disease. But none of them are perfect. I am fond of the carpal tunnel six questionnaire. This is used to measure symptom severity and treatment outcomes, six-item carpal tunnel symptom scale, and you can decide how you're going to do this. You can put some of these into Epic if you're using an electronic health record and start clicking them and use it in this way. But this looks at the global view of the patient. How severe are the following symptoms in your hand? None, mild, moderate, severe, very severe. How often did the following symptoms wake you up at night? Never more than five times. And this gives you a global picture of evaluation of the patient. I also love Brent Graham's article, 2008, JBJS. When you start looking at probabilities, if you have three or more of any of these, you have at least an 85% chance, about 80% chance of having carpal tunnel. This was done by Delphi analysis of experts in the field, and I found it quite useful because it isn't a perfect thing. You at the beginning of your career or in somebody who is a high-risk patient may say, you know, I need you to have four of these things. I need you to have five of them. You can choose kind of how much risk you're willing to take and how comfortable you need to be about a diagnosis. And for some patients, you may really want a little bit more confidence that something is true or not true. But it's, again, a group of things. With respect to adjunctive tests, there's been no evidence that an EMG and a nerve conduction study are any better than any of your physical exam tests. I know that we get them a lot because of legal reasons, but I've seen people who have responded beautifully to surgery. They've had everything else positive in the physical exam and their history, but the EMG is only marginally different. I tend to, you know, especially in elderly patients, I'll do a steroid injection for a more confirmatory thing, but I do not use the EMG to the exclusion of every other thing in my evaluation of the patient. Ultrasound has been found to be similarly effective as EMG nerve conduction studies. And that's an interesting thing, and it's a lot less uncomfortable to patients. I made my husband get one, and he really wasn't thrilled with his being poked by the needles. And you have a lot of people who have residual discomfort after them. They're very expensive. They're time-consuming. And so it isn't just, oh, go and get an EMG. You really have to decide why you want to get this study because it isn't as useful as you may think. Ultrasound can be useful, and many people are getting these into their offices, and you can decide if you want to take an ultrasound course. At the level of the pisiform, you know, is where if you see a nerve compression, then, you know, you probably have some problem with your median nerve. MRI are also sensitive, but again, really expensive, $1,300 to $1,500 for the test. X-rays, only if you're trying to rule out some other problem. And then steroids. For somebody who has an unclear diagnosis, for an elderly patient, you know, over about 75 or 80, I'll get these to see if it helps at all. And, you know, so it's been a useful addition to my armamentarium. If patients say that the steroid injection or the local anesthetic made their pain worse, then I have real severe concerns about, you know, maybe issues of secondary gain. You know, it's probably unlikely that I hit the median nerve while I'm doing it because they're awake, but they can be helpful to you in your practice. So now we're going to go on to... Amy will be next. Thank you. I would ask that we could hold questions until the very end. Thanks. Thank you.

Carpal tunnel surgery

Carpal tunnel syndrome

Physical examination

Nerve conduction studies

Effective communication