Practice Parameter and Literature Review of the Usefulness of ...

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AAEM PRACTICE TOPIC IN ELECTRODIAGNOSTIC MEDICINEAmerican Association of Electrodiagnostic Medicine421 First Avenue S.W., Suite 300 East, Rochester, MN 55902 (507/288-0100)© 2002 American Association of Electrodiagnostic MedicineMuscle Nerve 25: 918–922, 2002PRACTICE PARAMETER FOR ELECTRODIAGNOSTICSTUDIES IN CARPAL TUNNEL SYNDROME:SUMMARY STATEMENT*AMERICAN ASSOCIATION OF ELECTRODIAGNOSTIC MEDICINE, AMERICAN ACADEMY OF NEUROLOGY,and AMERICAN ACADEMY OF PHYSICAL MEDICINE AND REHABILITATIONCarpal tunnel syndrome (CTS) is a commonclinical problem and frequently requires surgicaltherapy. The results of electrodiagnostic (EDX)studies have been found to be highly sensitive andspecific for the*Approved by the American Association of ElectrodiagnosticMedicine: January 2002, original document approved April 1993.Approved by the American Academy of Neurology: February 2002,original document endorsed, February 1993. Endorsed by theAmerican Academy of Physical Medicine and Rehabilitation:February 2002, original document endorsed, March 1993.Reviewed and revised in 2001 by the American Association ofElectrodiagnostic Medicine (AAEM) CTS Task Force: Charles KJablecki, MD, Chair; Michael T. Andary, MD, MS; Mary Kay FloeterMD, PhD; Robert G. Miller, MD; Caroline A. Quartly, MD, FRCP(C);Michael J. Vennix, MD; John R. Wilson, MD. American Academy ofNeurology (AAN) Quality Standards Subcommittee: Gary M. Franklin,MD, Co-chair; Catherine A. Zahn, MD, FRCP(C), MHSc, Co-chair;Milton Alter, MD, PhD; Stephen Ashwal, MD; Rose M. Dotson, MD;Richard M. Dubinsky, MD; Jacqueline French, MD; Gary H. Friday,MD; Michael Glantz, MD; Gary S. Gronseth, MD; Deborah Hirtz, MD;James Stevens, MD; David J. Thurman, MD, MPH; William Weiner,MD. American Academy of Physical Medicine and Rehabilitation(AAPM&R) Practice Guidelines Committee: John C. Cianca, MD;Gerard E. Francisco, MD; Thomas L. Hedge, Jr., MD; Deanna M.Janora, MD; Ajay Kumar, MD; Gerard A, Malanga, MD; Jay M.Meythaler, MD, JD; Frank J. Salvi, MD; Richard D. Zorowitz, MD.Authors had nothing to disclose.Original document developed in 1993 by the AAEM QualityAssurance Committee: Charles K. Jablecki, MD, Chair; Michael T.Andary, MD, MS; Richard D. Ball, MD, PhD; Michael Cherington, MD;Morris A Fisher, MD; Lawrence H. Phillips II, MD; Yuen T. So, MD,PhD; John W. Tulloch, MD; Margaret A. Turk, MD; David O.Wiechers, MD, MS; Asa J. Wilbourn, MD; Dennis E. Wilkins, MD;Faren H. Williams, MD; Roy G. Ysla, MD. American Academy ofNeurology (AAN) Quality Standards Subcommittee: Jay H.Rosenberg MD, Chair; Milton Alter, MD, PhD; Jasper R. Daube, MD;Gary Franklin, MD, MPH; Benjamin M. Frishberg, MD; Michael K.Greenberg, MD; Douglas J. Lanska, MD; George Paulson, MD;Richard A. Pearl, MD; Cathy A. Sila, MD. American Academy ofPhysical Medicine and Rehabilitation (AAPM&R) Practice ParametersCommittee: Carl V. Granger, MD, Chair; Joel A. DeLisa, MD; MyronM. LaBan, MD; James S. Lieberman, MD; Mark A. Tomski, MD;Margaret A. Turk, MD.Key words: carpal tunnel syndrome; electromyography; literaturereview; nerve conduction study; reference values; sensitivity;specificityCorrespondence to: American Association of ElectrodiagnosticMedicine; e-mail: aaem@aaem.net© 2002 American Association of Electrodiagnostic Medicine.Published by Wiley Peridodicals, Inc.Published online 7 May 2002 in Wiley InterScience(www.interscience. wiley.com). DOI 10.1002/mus.10185diagnosis of CTS. This document defines thestandards, guidelines, and options for EDX studiesof CTS based on a critical review of the literaturepublished in 1993 1 and recently updated by areview of the literature through the year 2000. 2 Thereader is referred to the updated review 2 for adetailed discussion of the literature and the EDXtechniques for the assessment of CTS which aresummarized here. Both reviews addressed thefollowing key clinical questions:1. In patients clinically suspected of having CTS,what are the best EDX studies to confirm thediagnosis?2. How can future clinical research studies beimproved to evaluate the usefulness oflaboratory studies, including EDX studies, toconfirm the diagnosis of CTS?DESCRIPTION OF THE REVIEW PROCESSThe source of the articles for the first CTSLiterature Review 1 published in 1993 was aMedline search for literature in English fromJanuary 1, 1986, through May 1991.The Medical Subject Headings (MeSH) searchedwere (1) wrist injuries or wrist joint, (2) nervecompression syndrome, and (3) carpal tunnelsyndrome. The search identified 488 articles.Based on a review of the abstracts, 81 articlesdescribing EDX studies were chosen for review.An additional 78 reports were identified from thebibliographies of the 81 articles, and AAEMconsultants recommended 6 others for a total of165 articles. Of the 165 articles reviewed, 20 wereclassified as background references. The source ofthe articles for the second CTS Literature Review 2was a Medline search for literature in Englishthrough December 2000. The MeSH searched918 AAEM Practice Topic MUSCLE & NERVE June 2002
were (1) carpal tunnel syndrome and diagnosis or(2) carpal tunnel syndrome and neural conduction.The search generated 497 article titles withabstracts published since 1990. Based on a reviewof the abstracts, the AAEM CTS Task Force chose92 articles for review. An additional 5 articleswere identified from the bibliographies of thearticles, and 16 from AAEM members who havecurrent research interests in CTS, for a total of 113articles. Of the 113 articles reviewed, 24 wereclassified as background references.DESCRIPTION OF THE REVIEWERSIn 1997, the AAEM President appointed Dr.Charles K. Jablecki to Chair the AAEM CTS TaskForce. The Chair selected the members of theAAEM CTS Task Force from the AAEMmembership with the assistance of the AAEM staffand the AAEM President to include neurologists(Floeter, Jablecki, Wilson) and physiatrists(Andary, Quartly, Vennix) in both academic(Andary, Floeter, Quartly, Vennix) and clinicalpractice (Jablecki, Wilson) with interests in the useof EDX studies in CTS. The AAEM CTS TaskForce included three members who authored thefirst CTS Literature Review published in 1993(Jablecki, Andary, Wilson). In 1999, the AAEMPresident appointed Dr. Robert G. Miller to theAAEM CTS Task Force to provide an interfaceand full collaboration with the AAN QualityStandards Subcommittee in the development of thesecond CTS Literature Review and the SummaryStatement.LITERATURE INCLUSION CRITERIAIn the fall of 1991, the AAEM Quality AssuranceCommittee adopted six literature inclusion criteria(LIC) of scientific methodology to evaluate CTSliterature describing EDX procedures. The AAEMCTS Task Force used the same six AAEM CTSLIC when reviewing the literature. The first twocriteria apply to all studies of diagnostic tests anddeal with the quality of evidence and reducingbias; the remaining four criteria deal with technicaland analytic issues that are critical to the use ofnerve conduction studies (NCSs) to documentnerve pathology. All of these criteria are importantfor a study to determine whether or not a NCS isuseful to diagnose CTS. The six LIC used were asfollows:1. Prospective study design.2. Diagnosis of CTS in patient population basedon clinical criteria independent of the EDXprocedure under evaluation.3. EDX procedure described in sufficient detailto permit replication of the procedure.4. Limb temperature monitored (measuredcontinuously) during nerve conductionprocedures and minimum (or range) of limbtemperatures reported for both CTS patientsand the reference population.5. Reference values for the EDX test obtainedeither:a) with concomitant studies of a referencepopulation, orb) with previous studies of a referencepopulation in the same laboratory.6. Criteria for abnormal findings clearly statedand, if the measurement is a quantitative one,the abnormal value is defined in statisticallycomputed terms, e.g., range and mean ± 2standard deviations, from data derived fromthe reference population.REVIEW OF ELECTRODIAGNOSTIC STUDIESA total of 22 of the 278 articles reviewed met all 6AAEM CTS LIC. There were nine additionalarticles (eight using surface electrodes and oneusing needle electrodes) that studied median motorand sensory nerve conduction across the carpaltunnel (amplitude, latency, and velocity) in normalsubjects only and otherwise fulfilled the AAEMCTS LIC.The first and second CTS Literature Reviews 1,2provide convincing, scientific evidence thatmedian sensory and motor NCSs:1. are valid and reproducible clinical laboratorystudies; and2. confirm a clinical diagnosis of CTS with ahigh degree of sensitivity (>85%) andspecificity (95%).Table 1 provides a summary of pooled sensitivitiesand specificities from studies that met all sixAAEM CTS LIC for EDX techniques used todiagnose CTS. In these studies, hand temperatureswere monitored continuously and the majority ofthe studies maintained the hand temperature at32°C or greater. Details of techniques and thespecific studies pooled are provided in the secondCTS Literature review. 2DEFINITION OF PRACTICE RECOMMENDATIONSTRENGTHSThe strength of a recommendation or conclusion isAAEM Practice Topic MUSCLE & NERVE June 2002 919
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