How Can We Reduce the Cost of Treatment for Carpal Tunnel Syndrome?
With health care costs soaring, everyone is looking for ways to trim the budget. Taking common problems like carpal tunnel syndrome (CTS) and doing a cost analysis between operative and nonoperative treatment makes a lot of sense. It can help patients and surgeons in the decision-making process.

Carpal tunnel syndrome is a problem affecting the hand and wrist with pain, numbness, and weakness occurring when the median nerve gets squeezed inside the carpal tunnel of the wrist. This condition is also known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of carpal tunnel syndrome.

Why start with a cost analysis of treatment for carpal tunnel syndrome? Well, it is one of the most common hand problems surgeons see, affecting as much as nine per cent of the adult population at any given point in time. And although it's recommended that anyone with carpal tunnel symptoms start with conservative (nonoperative) care first, the results of this study suggest just the opposite. Surgery should be the standard of care for anyone with electrodiagnostically proven carpal tunnel syndrome.

That phrase electrodiagnostically proven is the important key. Symptoms of wrist pain and numbness of the thumb, first two fingers, and half of the ring finger come with carpal tunnel syndrome. But unless electrodiagnostic tests are done, the patient does not have a confirmed, proven case of carpal tunnel syndrome.

What tests are we talking about? Several tests are available to see how well the median nerve is functioning, including the nerve conduction velocity (NCV) test and an electromyogram (EMG). The NCV test measures how fast nerve impulses move through the nerve. Slow or absent impulses is a sign that the nerve is not firing properly.

The EMG is done by testing the muscles of the forearm and wrist that are controlled by the median nerve to determine if they are working properly. If the test shows a problem with the muscle, the nerve that goes to the muscle might not be working correctly. This is similar to checking whether the wiring in a lamp is working. If the light still doesn't work after you've put in a new bulb, you can begin to tell if there's a problem in the wiring.

Knowing that nerve function is affected helps steer patients to surgery right away because this is not something that responds well to treatment with splinting or hand therapy. Rather than spending money on conservative care and still ending up with surgery, costs can be cut up front by beginning with surgery first.

To prove this, the authors divided a group of 120 patients with carpal tunnel syndrome into two groups. People in the two groups were matched so there was no difference between the groups based on gender, age, body mass index, tobacco use, type of employment, and insurance coverage. They were also equally matched based on the results of nerve conduction testing. No one in either group had a previous history of surgery for carpal tunnel syndrome.

The first group had at least two weeks of therapy with a hand therapist and then continued their exercises at home on their own. The program included wrist splinting at night and tendon/nerve gliding exercises. Steroid injections were also available for anyone in this group who were not improving. Group two had surgery without conservative care first. The surgeon performed an open incision and release of the transverse carpal ligament, sometimes referred to as the retinaculum. The procedure is called a carpal tunnel release.

Patients in group one could opt for surgery at any time if their symptoms were not improving with therapy or getting worse despite therapy. Anyone who switched from conservative care to surgical care was called a crossover patient. Patients in group two could have supervised hand therapy after surgery if needed to regain motion, strength, and function but this was not ordered routinely. Everyone was followed at regular intervals (two weeks, six weeks, three months, and six months after treatment).

As a measure of outcome, the authors added up all of the reimbursement received for services rather than the actual charges (since this was a study to compare actual costs). Items for which actual dollars were paid included surgeons' fees, anesthesia, operating room costs, splints, therapists, injections, and testing. Reimbursement came through one of three sources: Medicare, private insurance, and Workers' Compensation. The number of crossover patients was also added up. Patient characteristics were compared between those who crossed over and those who did not to help identify who should opt for surgery as the initial form of treatment.

Here's what they found. More than half of the patients in group one (nonsurgical care) crossed over and had surgery. Half of the crossovers tried everything including steroid injections but gained no improvement in their symptoms. They were able to delay surgery by several months compared with those who did not have the injections. Patients who had the most severe symptoms and who had jobs with the heaviest type of labor were the most likely to cross over.

Cost of conservative care varied depending on who was paying for it. Costs were the highest for Workers' Compensation patients and lowest for Medicare patients. Remember, these figures aren't based on what was charged for services. These dollars paid reflect what the various organizations would pay for the services (i.e., reimbursement).

As might be expected, the patients who started in group one and crossed over to group two had the highest costs. Patients who had conservative care with successful results usually had only mild symptoms of carpal tunnel syndrome. Their average costs were the lowest ($2,000 as opposed to $8,500 for surgery). It should be noted that all the patients in group one who did not cross over had continued symptoms that improved with conservative care, but did not go away completely.

The authors also took a look at the results of other cost-studies and found that there are different results depending on how the studies are done. For example, some studies included direct and indirect costs. Things like lost productivity, disability payments, and time and cost driving to and from treatments were factored in. Then there's the difference in costs from one region to another and one surgeon to another. Clearly, the payment structure (Medicare vs. Workers' Compensation vs. private insurance) makes a difference.

The authors conclude that patients with electrodiagnostically identified carpal tunnel syndrome are best served by having surgery as their first treatment approach. Those who do not want surgery may opt for conservative care but the results may be less than satisfactory and the costs will be higher if they end up having surgery in the end.
Jay Pomerance, MD, et al. The Cost-Effectiveness of Nonsurgical Versus Surgical Treatment for Carpal Tunnel Syndrome. In The Journal of Hand Surgery. September 2009. Vol. 34. No. 7. Pp. 1193-1200.