Appendix A. Sample Matrix of Clinical Scenarios Rating Sheet: Mild Symptoms of Carpal Tunnel Syndrome
Less Than High Probability Presentation
I. It is appropriate to
perform CTS in a patient
with signs/symptoms of
MILD carpal tunnel
syndrome
AND symptom duration < 3
months AND
a. equivocal or
no EMG/NCS*
b. positive EMG/NCS
c. negative EMG/NCS
AND symptom duration 3-12
months AND
a. equivocal or
no EMG/NCS*
b. positive EMG/NCS
c. negative EMG/NCS
AND symptom duration > 12
months AND
a. equivocal or
no EMG/NCS*
b. positive EMG/NCS
c. negative EMG/NCS
High Probability Presentation
without attempted
conservative
treatment
attempted
conservative
treatment
without attempted
conservative
treatment
attempted
conservative
treatment
1 2 3 4 5 6 7 8 9^
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
*Category also included poor quality electrodiagnostic tests; however, such tests may be challenging for providers to identify unless they perform
electrodiagnosis themselves. ^ 1-9 represent the rating options. 1-3= risks substantially outweigh benefits of surgery (inappropriate); 4-6= neither risks or
benefits of surgery outweigh the other (optional); 7-9= benefits substantially outweigh risks of surgery (necessary).
1
Appendix B. Measures Summarizing Scenarios for Which Carpal Tunnel Surgery Was Judged to Be
Necessary
Measure
Number
1
Measure Text
IF a patient has MILD carpal tunnel syndrome present for any length of time AND all of the following cr
the patient MUST be offered CTS:
1. An attempt at conservative therapy has failed,
2. The presentation is “high probability”,
3. An electrodiagnostic test is positive for carpal tunnel syndrome
2
IF a patient has MODERATE carpal tunnel syndrome present for up to 12 months AND all of the followin
THEN the patient MUST be offered CTS:
1. An attempt at conservative therapy has failed,
2. The presentation is "high probability",
3. An electrodiagnostic test is positive for carpal tunnel syndrome
3
IF a patient has MODERATE carpal tunnel syndrome present for more than 12 months AND both of the
are met THEN the patient MUST be offered CTS:
1. Either or both of the following:
a. An attempt at conservative therapy has failed AND/OR
b. The presentation is “high probability”
2. An electrodiagnostic test is positive for carpal tunnel syndrome
4
IF a patient has SEVERE carpal tunnel syndrome present for any length of time AND both of the followin
THEN the patient MUST be offered CTS:
1. The presentation is “high probability”,
2. An electrodiagnostic test is positive for carpal tunnel syndrome
5
IF a patient has SEVERE carpal tunnel syndrome present for less than 3 months AND all of the following
THEN the patient MUST be offered CTS:
1. An attempt at conservative therapy has failed,
2. The presentation is “high probability”,
3. An electrodiagnostic test has not been performed, or has produced an indeterminate result
6
IF a patient has SEVERE carpal tunnel syndrome present for more than 12 months AND all of the follow
THEN the patient MUST be offered CTS:
1. An attempt at conservative therapy has failed,
2. The presentation is “high probability”,
3. An electrodiagnostic test has not been performed, or has produced an indeterminate result
2
Appendix C. Measures Summarizing Scenarios for Which Carpal Tunnel Release Surgery Was
Judged to Be Inappropriate
Measure
Number
1
Measure Text
IF a patient has MILD carpal tunnel syndrome present for any length of time AND both of the following
THEN the patient should NOT undergo carpal tunnel release surgery:
1. Either or both of the following:
a. Conservative therapy has not been attempted or has adequately resolved the patient’s symptoms,
b. The presentation is less than “high probability”
2. An electrodiagnostic test has not been performed, or was negative or indeterminate for carpal tunne
2
IF a patient has MILD carpal tunnel syndrome present for up to 12 months AND all of the following crite
the patient should NOT undergo CTS:
1. Conservative therapy has not been attempted or has adequately resolved the patient’s symptoms,
2. The presentation is less than “high probability”,
3. An electrodiagnostic test is positive for carpal tunnel syndrome
3
IF a patient has MODERATE carpal tunnel syndrome present for less than 3 months AND both of the fol
met THEN the patient should NOT undergo CTS:
1. Either or both of the following:
a. Conservative therapy has not been attempted or has adequately resolved the patient’s symptoms,
b. The presentation is less than “high probability”
2. An electrodiagnostic test has not been performed, or was negative or indeterminate for carpal tunne
4
IF a patient has MODERATE carpal tunnel syndrome present for less than 3 months AND all of the follow
met THEN the patient should NOT undergo CTS:
1. Conservative therapy has not been attempted or has adequately resolved the patient’s symptoms,
2. The presentation is less than “high probability”,
3. An electrodiagnostic test is positive for carpal tunnel syndrome
5
IF a patient has MODERATE carpal tunnel syndrome present for 3 months or longer AND both of the fo
met THEN the patient should NOT undergo CTS:
1. Either or both of the following:
a. Conservative therapy has not been attempted or has adequately resolved the patient’s symptoms,
b. The presentation is less than “high probability”
2. An electrodiagnostic test is negative for carpal tunnel syndrome
6
IF a patient has MODERATE carpal tunnel syndrome present for 3 months or longer AND all of the follo
met THEN the patient should NOT undergo CTS:
1. An attempt at conservative therapy has not been attempted or has adequately resolved the patient’
2. An electrodiagnostic test has not been performed, or was indeterminate for carpal tunnel syndrome
3