Information for general practitioners

GPs within the area covered by the East Kent and Coastal Primary Care Trust and its successor CCGs have the option of referring patients with suspected carpal tunnel syndrome who live in this area directly to the neurophysiology service for both diagnosis and management of their CTS. 

Changes to the referral pathway and COVID-19

Even before the COVID outbreak we had been discussing with the CCGs the possibility of using the website symptom questionnaire as an initial triage step in assessing whether patients should be tested for CTS. The epidemic has led to us implementing this change rather earlier. The clinic will now only be accepting referrals for new patients who score >= 20% on the diagnostic questionnaire. We will of course continue to see patients with known CTS who we have been treating but note that these patients should not be bothering you anyway - they can refer themselves directly back to the CTS clinic. Your first step in referring a patient to me for CTS should therefore now be to ask them to complete the questionnaire here. Patients with scores less than 20% should be referred to musculoskeletal triage, hand surgery, neurology or rheumatology depending on their symptom pattern.

If your patient completes the online questionnaire at home and prints out the summary document from the result page they can bring that to you and you can use it as the test request form to be sent on to me. You can also, if you wish, ask patients to email me directly at Jeremy [dot] Bland [at] nhs [dot] net once they have completed the questionnaire and I will advise them what to do next. If you take this route then please ask the patient to include your name and practice and their NHS number in the email to me. You can also continue to use the existing request form but please write on it the website diagnostic score and/or Questionnaire reference number (see below) when referring. It is no longer necessary for website users to register/create an account but if they answer the questionnaire anonymously without doing so then they MUST make a note of the Questionnaire reference number which is displayed when the questionnaire is finished, or shown on the printed version. If either you or the patient sends this number to me I will be able to find that questionnaire and act on it.

Special cases

1) No web access - We have found over the last few years that very few East Kent patients are totally unable to access the internet to complete the questionnaire, though some require the assistance of friends and family. If you have a patient who is truly completely non-digital and the practice itself is not able to help them complete the questionnaire then I can send them a paper version which they can complete and return to me but this will be considerably slower and should be an absolute last resort. The paper version is more vulnerable to being incompletely or ambiguously filled out and having to be sent back again for clarification too. If we really have to tackle a patient in this way please email me their full name/address/ NHS number and your name and practice.

2) The AI gets it wrong - In rare cases the website is dramatically wrong about the diagnosis. This is most likely to happen with familial CTS occurring in very young patients, in which case the weighting applied to age diagnostically can outweigh what otherwise seem to be classic CTS symptoms. I do review the questionnaire answers when I am notified that one has been completed and will occasionally over-ride the verdict of the AI but if you have a patient under the age of 25 years with nocturnal paraesthesiae in a typical median nerve distribution and three or more family members with CTS then please contact me about that patient directly, preferably by email. These cases are very rare! For the most part the website is right in it's assessment of the probability of CTS. We have prospectively tested it in 2821 referrals and published the results in an open access paper if you are interested.

Please note.The protocol does not deal with new presentations with recurrent CTS after decompression years previously, though we are of course happy to review patients who have had treatment within the CTS protocol and who still have problems and you can still refer patients with late recurrences of symptoms for testing - we simply do not accept them as cases for treatment because true recurrence of CTS is very rare, difficult to deal with, and deserves the attentions of a specialist hand surgeon.

We do not take conditional referrals to the scheme - ie 'please arrange treatment only if surgery is needed otherwise leave it to me'. There is still inadequate evidence of the outcomes of conservative treatment for CTS and I believe that all conservatively treated patients should be monitored using the mechanisms we have in place in this scheme. We would however like more GPs who know how to inject the carpal tunnel to join our pool of injectors - if you are interested please contact me.

Patients referred to the scheme will be tested for CTS only. If we discover evidence of other problems in passing we may not have time to fully explore these in the CTS clinic and cannot guarantee to do this, though we will if we happen to have time.

Patients with normal nerve conduction studies will normally be returned to you for further management. However, now that we can also carry out high resolution ultrasound scanning for CTS in the clinic we will investigate patients who have competed the web based symptom questionnaire and scored >70% with ultrasound also and if this is supportive of a diagnosis of CTS we will treat them too. A few patients with negative neurophysiology and ultrasound may still have CTS as both tests do have a small false negative rate, but I do not believe that these patients require urgent surgical intervention. Most will either declare themselves as other pathology, remit spontaneously, or show more definite evidence of CTS within 6 months or so. Patients with symptoms which sound like CTS should be encouraged to try a wrist splint.

For those patients who do have test results consistent with CTS and an appropriate history I will discuss the diagnosis and possible management with the patient. I have a stock of splints which I can hand out immediately but I would strongly urge you to try this very simple measure with any patient suspected of having CTS before referral to neurophysiology. Splints are inexpensive, entirely harmless and in a small proportion of patients may be the only treatment required. If the patient has symptoms suggestive of CTS which resolve after a few weeks of night splinting and do not recur on discontinuing use of the splint then you do not need to refer them to me.

The scheme is intended as an example of shared care. If you refer patients to the protocol then you may be asked to assist with occasional other investigations, referrals to other specialities, or follow-up and documentation of outcomes. If you are not prepared to do this then do not refer your patients to the scheme. You can still refer patients for NCS for CTS outside the scheme but they still have to have scored >= 20% onthe web questionnaire..

It may eventually be possible to make a referral directly from this web site but for the present please either use the dedicated request form endorsed with the website score, or an exact equivalent, or the printed questionnaire summary from this site. The CTS clinic is NOT accessible via ‘Choose and Book’ and requests should be sent direct to neurophysiology and not to the patient service centre. Incomplete request forms will be returned. For referrals to the CTS pathway the patient MUST now have a website score of >= 20%. If you send patients to me it will now be assumed that you are willing to participate in their follow-up unless you explictily write to me and specify otherwise.

Other indications for EMG/Nerve conduction studies - There is open access for the investigation of suspected ulnar neuropathy at the elbow and I am also happy to see again patients in whom I have suggested in an earlier report that repeat studies might be appropriate for any diagnosis, but other problems - peripheral neuropathy, other entrapment syndromes, MND, myasthenia, injuries, and especially patients in whom there is no obvious clinical diagnosis! - should be referred to one of my clinical colleagues of an appropriate speciality. Please do not use the CTS-protocol referral form for other nerve problems as this leads to patients being booked in to the wrong clinic and pestered with inappropriate questionnaires.

All requests for EMG/NCS, CTS protocol or otherwise, MUST originate with a permanent, medically qualified practitioner, not with a locum, trainee, nurse, physiotherapist etc. I also dislike and usually reject ‘second hand’ referrals, where another doctor (or especially a non-medical person of any kind) has asked you to make a request on their behalf - such doctors should do it themselves.

STEROID POLICY

The scheme makes extensive use of steroid injection for the treatment of CTS. So far as possible we have tried to standardise this.

Steroid and dose - Triamcinolone acetate, 40mg WITHOUT added or prior local anaesthetic

Injection site - 2-4cm proximal to the wrist crease between the tendons of palmaris longus and flexor carpi radialis, or, if you prefer, some surgeons inject through the FCR tendon.

Precautions/Contra-indications - There are no absolute contra-indications to steroid injection of the carpal tunnel but the following should be noted:

Pregnancy - Avoid injecting in the 1st trimester of pregnancy

Anticoagulants/Warfarin - INR should be below 2.5 with no obvious bleeding.

Diabetes - patients should be warned of the possibility of disturbance of their glycaemic control for a few days

Impending surgery, coughs and colds, other medications, lymphoedema/previous breast surgery on that side, immunosuppression and the use of oral steroids, should not be a bar to injection

Laterality - Inject both sides at the same visit when both are symptomatic - we do not inject asymptomatic hands, even if the nerve conduction results are abnormal. Occasionally it may be appropriate to inject one side and then follow up with the other at the first review appointment, usually when there is uncertainty about the diagnosis of CTS.

Follow-up - review the patient approximately 6 weeks after injection and record the overall subjective response to treatment (worse, unchanged, slightly better, much better, complete cure) for BOTH hands - even when the other hand is asymptomatic, has not been injected and has not changed!

a) the best response obtained during the 6 weeks

b) the current response at 6 weeks (a few patients will have had a good response for a week or two followed by some deterioration).

c) Complete a 'Boston' symptom severity and functional impairment score for each hand - even when only one hand has been injected and even when the CTS is strictly unilateral! - this may be done on paper or online on this website if the patient is registered.

Further action - patients who are well can be followed up further by their own GP but are free to contact the carpal tunnel clinic directly if and when symptoms recur without bothering their GP (contact details here). We hope that this somewhat reduces the load on primary care in exchange for our occasional requests for assistance with follow-up. Those who have not responded to injection will be contacted by me with a view to further treatment.

Repeat injection - Injections may be repeated indefinitely so long as the intervals between injections average at least 6 months and the nerve conduction studies are not deteriorating markedly. One set of nerve conduction studies may generally be considered to be valid for 6-12 months so long as the patient does not think their symptoms are significantly worse than they were at the time of the previous NCS. Patients should be fully informed of the 'experimental' nature of treatment by serial injection and the unknown magnitude and type of any risks involved. We do not at present feel that a formal consent form is required however (This has changed during the COVID epidemic because of concerns that steroids might aggravate COVID-19 infection - notwithstanding recent evidence of benefit from dexamethasone in seriously ill patients). Patients who have noticed a definite deterioration overall should be re-tested before injection, as should those who originally had grade 4 or above CTS, and in any case if 12 months or more have passed since the previous set.

Note that following this management pathway contravenes official guidance from the Federation of European Societies for Surgery of the Hand who recommend a maximum of three injections in one wrist. (Huisstede 2014)

Other specific issues are covered in the injection FAQ list.

There are a few GPs in East Kent who carry out steroid injections for CTS outside the CTS pathway and then subsequently ask me to take over the management of the patient for surgery. I would be grateful if they could document their injections to the standard specified above when making such referrals and forward all this information with the patient referral. I would prefer it overall if patients were NOT injected before an initial set of nerve conduction studies, and especially not in the few weeks immediately before I am going to test them as this makes the test results very hard to interpret.

Revision date - 28th July 2020

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