Ultrasound as a First-line Test in the Diagnosis of Carpal Tunnel Syndrome: A Cost-effectiveness Analysis
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).
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.
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.
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.
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. CrossRef
- 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.
- Beekman R, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the literature. Muscle Nerve. 2003;27:26–33. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- Duncan I, Sullivan P, Lomas F. Sonography in the diagnosis of carpal tunnel syndrome. AJR Am J Roentgenol. 1999;173:681–684.
- 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. CrossRef
- Glowacki KA, Breen CJ, Sachar K, Weiss AP. Electrodiagnostic testing and carpal tunnel release outcome. J Hand Surg Am. 1996;21:117–121. CrossRef
- Graham B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2008;90:2587–2593. CrossRef
- 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.
- Grundberg AB. Carpal tunnel decompression in spite of normal electromyography. J Hand Surg Am. 1983;8:348–349.
- Iyer VG. Understanding nerve conduction and electromyographic studies. Hand Clin. 1993;9:273–287.
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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. CrossRef
- 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.
- 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. CrossRef
- 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. CrossRef
- Nakamichi KI, Tachibana S. Enlarged median nerve in idiopathic carpal tunnel syndrome. Muscle Nerve. 2000;23:1713–1718. CrossRef
- Nathan PA, Keniston RC, Meadows KD, Lockwood RS. Electrodiagnostic testing in hand surgery. J Hand Surg Am. 1997;22:948–949. CrossRef
- 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. CrossRef
- 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. CrossRef
- Sarria L, Cabada T, Cozcolluela R, Martinez-Berganza T, Garcia S. Carpal tunnel syndrome: usefulness of sonography. Eur Radiol. 2000;10:1920–1925. CrossRef
- Social Security Administration National Average Wage Index. Available at: http://www.ssa.gov/OACT/COLA/AWI.html. Accessed March 2, 2012.
- 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. CrossRef
- 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.
- 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. CrossRef
- 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. CrossRef
- Wong SM, Griffith JF, Hui AC, Lo SK, Fu M, Wong KS. Carpal tunnel syndrome: diagnostic usefulness of sonography. Radiology. 2004;232:93–99. CrossRef
- 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. CrossRef
- Ultrasound as a First-line Test in the Diagnosis of Carpal Tunnel Syndrome: A Cost-effectiveness Analysis
Clinical Orthopaedics and Related Research®
Volume 471, Issue 3 , pp 932-937
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- 1. Department of Orthopaedics, University of Pittsburgh Medical Center, Kaufmann Medical Building, Suite 1010, 3471 Fifth Avenue, Pittsburgh, PA, 15123, USA
- 2. Rothman Institute, Philadelphia, PA, USA