Carpal Tunnel Syndrome A clinical audit of the local service Dr Elena Nikiphorou Dr Adam Young Suzanne Jenkins (Research Assistant)

Background Incidence: 1 per 1000 people/year Prevalence: 3% population Gender/age: commoner in F 4:1, peak 45-54 in F, increases with age in M Pathogenesis: compression of median nerve within the carpal tunnel

APB muscle wasting

Management Clinical CTS Severe symptoms/atypical presentation/uncertain diagnosis Mild symptoms, no clinical signs Moderate symptoms & sensory signs Simple analgesics NSAIDs Wrist splints OT Weight reduction Cortisone injection EMG/NCS Day case decompression surgery Care pathway adapted from Laitner & Young (2004)

Why audit? WHHT 2009/10: Management varies between different hospitals Delays between symptom onset and treatment 1995 audit with St Albans GPs (51% did not receive any treatment while waiting for 1st hospital referral) WHHT 2009/10: 18 week pathway from GP referral to treatment Are we achieving this target? Does the one-stop clinic solve the problem?

Referral times 1985-1995 One stop One stop 12wks 32wks 4wks 10wks 12wks 24wks T=94wks Neuro OPD Rheuma OPD Ortho OPD Neuro OPD GP NCS/EMG Surgery 10wks 12wks 14 wks 26wks T=62wks Rheuma OPD Ortho OPD GP NCS/EMG Surgery 1995 10wks 20wks T=30wks Rheuma OPD + NCS/EMG Surgery GP One stop One stop Jayakumar K. BJR 2006;45(S1):262

One-Stop CTS clinic Introduced at SACH & HHGH in 1995 Clinical assessment (15-30 minutes) EMG/NCS (15-30 minutes) Diagnosis ? CTS or not ? Radicular origin e.g. C5/6/7 ? Both (“double crush”) ? neuropathy, MND Further investigations e.g. x-rays C-spine, wrist ultrasound Assessment of need for surgery or other treatments

Audit Source and type of referrals Times from referral to EMG/NCS to surgery Patient satisfaction Questionnaires sent to 235 patients, seen between 2006-2010

Graph 1: Yearly Total CTS procedures Days Year

Graph 2: MSK referrals 2010

Graph 3: Times to EMG/NCS clinic 360 GP referrals per year Days Year

Graph 4: Times from EMG/NCS to surgery

Patient satisfaction questionnaire (PSQ) Symptom duration prior to EMG/NCS Symptom severity pre-treatment Symptom severity post-surgery Investigations & Treatment Overall satisfaction

PSQ – Rating of overall service 2

Conclusions A unique service Cost effective – reduced number of outpatient clinics (6 to 2!) Waiting times improved Improved patient convenience Improved overall patient satisfaction

Thank you!