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

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

3. APB muscle wasting

4. 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)

5. 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?

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

7. 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

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

9. Graph 1: Yearly Total CTS procedures
Days
Year

10. Graph 2: MSK referrals 2010

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

12. Graph 4: Times from EMG/NCS to surgery

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

14. PSQ – Rating of overall service 2

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

16. Thank you!