Top

Clinical Orthopaedics and Related Research®

Published in:

01-03-2013 | Clinical Research

Ultrasound as a First-line Test in the Diagnosis of Carpal Tunnel Syndrome: A Cost-effectiveness Analysis

Authors: John R. Fowler, MD, Mitchell G. Maltenfort, PhD, Asif M. Ilyas, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 3/2013

Abstract

Background

The American Academy of Orthopaedic Surgeons (AAOS) recommends that surgeons obtain a confirmatory test in patients for whom carpal tunnel surgery is being considered. The AAOS, however, does not specify a preferred test. Ultrasound reportedly causes less patient discomfort and takes less time to perform, while maintaining comparable sensitivity and specificity to electrodiagnostic testing (EDX).

Questions/purposes

We determined whether ultrasound as a first-line diagnostic test is more cost-effective than using EDX alone or using ultrasound alone: (1) when used by a general practitioner; and (2) when used by a specialist.

Methods

A fictional population of patients was created and each patient was randomly assigned a probability of having true-positive, false-positive, true-negative, and true-positive ultrasound and EDX tests over an expected range of sensitivity and specificity values using Monte Carlo methods. Charges were assigned based on Medicare charges for diagnostic tests and estimates of missed time from work.

Results

The average charge for the use of ultrasound as a first-line diagnostic test followed by EDX for confirmation of a negative ultrasound test was $562.90 per patient in the general practitioner scenario and $369.50 per patient in the specialist scenario, compared with $400.30 and $428.30 for EDX alone, respectively.

Conclusions

The use of diagnostic ultrasound as a first-line test for confirmation of a clinical diagnosis of carpal tunnel syndrome is a more cost-effective strategy in the specialist population and results in improved false-negative rates in the generalist population despite increased cost.

Level of Evidence

Level III, economic and decision analyses. See the Guidelines for Authors for a complete description of levels of evidence.

Altinok T, Baysal O, Karakas HM, Sigirci A, Alkan A, Kayhan A, Yologlu S. Ultrasonographic assessment of mild and moderate idiopathic carpal tunnel syndrome. Clin Radiol. 2004;59:916–925.PubMedCrossRef

Ashraf AR, Jali R, Moghtaderi AR, Yazdani AH. The diagnostic value of ultrasonography in patients with electrophysiologically confirmed carpal tunnel syndrome. Electromyogr Clin Neurophysiol. 2009;49:3–8.PubMed

Beekman R, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the literature. Muscle Nerve. 2003;27:26–33.PubMedCrossRef

Bland JD, Rudolfer SM. Clinical surveillance of carpal tunnel syndrome in two areas of the united kingdom, 1991–2001. J Neurol Neurosurg Psychiatry. 2003;74:1674–1679.PubMedCrossRef

Braun RM, Jackson WJ. Electrical studies as a prognostic factor in the surgical treatment of carpal tunnel syndrome. J Hand Surg Am. 1994;19:893–900.PubMedCrossRef

Cowan J, Makanji H, Mudgal C, Jupiter J, Ring D. Determinants of return to work after carpal tunnel release. J Hand Surg Am. 2012;37:18–27.PubMedCrossRef

Duncan I, Sullivan P, Lomas F. Sonography in the diagnosis of carpal tunnel syndrome. AJR Am J Roentgenol. 1999;173:681–684.PubMed

El Miedany YM, Aty SA, Ashour S. Ultrasonography versus nerve conduction study in patients with carpal tunnel syndrome: substantive or complementary tests? Rheumatology (Oxford). 2004;43:887–895.CrossRef

Fowler JR, Gaughan JP, Ilyas AM. The sensitivity and specificity of ultrasound for the diagnosis of carpal tunnel syndrome: a meta-analysis. Clin Orthop Relat Res. 2011;469:1089–1094.PubMedCrossRef

10.

Glowacki KA, Breen CJ, Sachar K, Weiss AP. Electrodiagnostic testing and carpal tunnel release outcome. J Hand Surg Am. 1996;21:117–121.PubMedCrossRef

11.

Graham B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2008;90:2587–2593.PubMedCrossRef

12.

Graham B, Regehr G, Naglie G, Wright JG. Development and validation of diagnostic criteria for carpal tunnel syndrome. J Hand Surg Am. 2006;31:919–924.PubMed

13.

Grundberg AB. Carpal tunnel decompression in spite of normal electromyography. J Hand Surg Am. 1983;8:348–349.PubMed

14.

Iyer VG. Understanding nerve conduction and electromyographic studies. Hand Clin. 1993;9:273–287.PubMed

15.

Jablecki CK, Andary MT, Floeter MK, Miller RG, Quartly CA, Vennix MJ, Wilson JR; American Association of Electrodiagnostic Medicine; American Academy of Neurology; American Academy of Physical Medicine and Rehabilitation. Practice parameter: electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2002;58:1589–1592.PubMedCrossRef

16.

Jablecki CK, Andary MT, So YT, Wilkins DE, Williams FH. Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. AAEM quality assurance committee. Muscle Nerve. 1993;16:1392–1414.PubMedCrossRef

17.

Keith MW, Masear V, Chung KC, Maupin K, Andary M, Amadio PC, Watters WC 3rd, Goldberg MJ, Haralson RH 3rd, Turkelson CM, Wies JL, McGowan R. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2009;91:2478–2479.PubMedCrossRef

18.

Kele H, Verheggen R, Bittermann HJ, Reimers CD. The potential value of ultrasonography in the evaluation of carpal tunnel syndrome. Neurology. 2003;61:389–391.PubMedCrossRef

19.

Koyuncuoglu HR, Kutluhan S, Yesildag A, Oyar O, Guler K, Ozden A. The value of ultrasonographic measurement in carpal tunnel syndrome in patients with negative electrodiagnostic tests. Eur J Radiol. 2005;56:365–369.PubMedCrossRef

20.

Kwon BC, Jung KI, Baek GH. Comparison of sonography and electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Hand Surg Am. 2008;33:65–71.PubMedCrossRef

21.

Lee D, van Holsbeeck MT, Janevski PK, Ganos DL, Ditmars DM, Darian VB. Diagnosis of carpal tunnel syndrome: ultrasound versus electromyography. Radiol Clin North Am. 1999;37:859–872, x.

22.

Moran L, Perez M, Esteban A, Bellon J, Arranz B, del Cerro M. Sonographic measurement of cross-sectional area of the median nerve in the diagnosis of carpal tunnel syndrome: correlation with nerve conduction studies. J Clin Ultrasound. 2009;37:125–131.PubMedCrossRef

23.

Nakamichi K, Tachibana S. Ultrasonographic measurement of median nerve cross-sectional area in idiopathic carpal tunnel syndrome: diagnostic accuracy. Muscle Nerve. 2002;26:798–803.PubMedCrossRef

24.

Nakamichi KI, Tachibana S. Enlarged median nerve in idiopathic carpal tunnel syndrome. Muscle Nerve. 2000;23:1713–1718.PubMedCrossRef

25.

Nathan PA, Keniston RC, Meadows KD, Lockwood RS. Electrodiagnostic testing in hand surgery. J Hand Surg Am. 1997;22:948–949.PubMedCrossRef

26.

Padua L, Pazzaglia C, Caliandro P, Granata G, Foschini M, Briani C, Martinoli C. Carpal tunnel syndrome: ultrasound, neurophysiology, clinical and patient-oriented assessment. Clin Neurophysiol. 2008;119:2064–2069.PubMedCrossRef

27.

Pastare D, Therimadasamy AK, Lee E, Wilder-Smith EP. Sonography versus nerve conduction studies in patients referred with a clinical diagnosis of carpal tunnel syndrome. J Clin Ultrasound. 2009;37:389–393.PubMedCrossRef

28.

Sarria L, Cabada T, Cozcolluela R, Martinez-Berganza T, Garcia S. Carpal tunnel syndrome: usefulness of sonography. Eur Radiol. 2000;10:1920–1925.PubMedCrossRef

29.

Social Security Administration National Average Wage Index. Available at: http://www.ssa.gov/OACT/COLA/AWI.html. Accessed March 2, 2012.

30.

Szabo RM, Slater RR Jr, Farver TB, Stanton DB, Sharman WK. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg Am. 1999;24:704–714.PubMedCrossRef

31.

United States Department of Health and Human Services AHRG. Healthcare Cost & Utilization Project (HCUP). Available at: http://www.ahrq.gov/data/hcup/. Accessed June 30, 2012.

32.

Visser LH, Smidt MH, Lee ML. High-resolution sonography versus EMG in the diagnosis of carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 2008;79:63–67.PubMedCrossRef

33.

Wiesler ER, Chloros GD, Cartwright MS, Smith BP, Rushing J, Walker FO. The use of diagnostic ultrasound in carpal tunnel syndrome. J Hand Surg Am. 2006;31:726–732.PubMedCrossRef

34.

Wong SM, Griffith JF, Hui AC, Lo SK, Fu M, Wong KS. Carpal tunnel syndrome: diagnostic usefulness of sonography. Radiology. 2004;232:93–99.PubMedCrossRef

35.

Yesildag A, Kutluhan S, Sengul N, Koyuncuoglu HR, Oyar O, Guler K, Gulsoy UK. The role of ultrasonographic measurements of the median nerve in the diagnosis of carpal tunnel syndrome. Clin Radiol. 2004;59:910–915.PubMedCrossRef

Title: Ultrasound as a First-line Test in the Diagnosis of Carpal Tunnel Syndrome: A Cost-effectiveness Analysis
Authors: John R. Fowler, MD
Mitchell G. Maltenfort, PhD
Asif M. Ilyas, MD
Publication date: 01-03-2013
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 3/2013
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-012-2662-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Ultrasound as a First-line Test in the Diagnosis of Carpal Tunnel Syndrome: A Cost-effectiveness Analysis

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 3/2013

CORR Insights™: Locking Buttons Increase Fatigue Life of Locking Plates in a Segmental Bone Defect Model

Reply to Letter to the Editor: The ACL in the Arthritic Knee: How Often is it Present and Can Preoperative Tests Predict its Presence?

CORR Insights™: Ultrasound as a First-line Test in the Diagnosis of Carpal Tunnel Syndrome: A Cost-effectiveness Analysis

50 Years Ago in CORR®: Synovial Sarcoma Kirk J. Anderson, MD and Orliss Wildermuth, MD CORR 1961;29:55–70

Can Radiographic Morphometric Parameters for the Hip Be Assessed on MRI?

Editorial: Research is a Team Sport: Updated Authorship Guidelines for CORR®