We discussed the following two articles from the October 2022 issue of JHS:
- The Utility of the Carpal Tunnel Syndrome-6 for Predicting the Outcomes of Carpal Tunnel Release by Francis J. Aversano, MD, Charles A. Goldfarb, MD, Richard H. Gelberman, MD, and Ryan P. Calfee, MD, MSc
- Is Midcarpal Arthroscopy for Suspected Scapholunate Pathology Associated With Greater Interobserver Agreement and More Frequent Offer of Surgery? by Daniel Bakker, MD, Gerald A. Kraan, MD, PhD, Joost W. Colaris, MD, PhD, Nina Mathijssen, MD, PhD, David Ring, MD, PhD, Tom J. Crijns, MD, and the Science of Variation Group
We thank everyone who joined us for the conversation. Please plan to join us next month and to use the TwChat platform. Please review the information here on how to use TwChat and join us in the fall!
Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
Brent Graham @BgTalkinman:
Welcome to the October session! Get the most from the session by using TwChat.com/hashtag/jhsjc #JHSJC
For anyone who might be interested in discussing these articles with our Eurozone colleagues consider joining in tomorrow’s discussion at 8 pm BST – 3 pm EDT, same location! #jhsjc
Let’s begin with the article about the #CTS6 and its value as a predictor of outcome. #jhsjc
RyanC @RPCalfeeSTL:
Welcome everyone #jhsjc
Warren @whammert:
While it would seem it should predict outcome as the article hypothesized, it was not as good as one might predict. Bud designed for diagnosis probability, so maybe we should not be surprised #jhsjc
RyanC @RPCalfeeSTL to @whammert:
Agree with you. We thought it might be associated with outcome but clearly not the purpose it was designed for #jhsjc
Brent Graham @BgTalkinman:
As the authors point out, #CTS6 identifies symptoms and physical exam findings of CTS – the more of those the higher probability of #CTS. The #BCTQ is a status instrument for #CTS & yet this study identifies no correlation between these two scales. Why not? #jhsjc
Warren @whammert to @BgTalkinman:
outcome and symptom relief are likely more related to night time awakening and not loss of 2PD, or provocative maneuvers #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
CTS6 scores findings but BCTQ more about functional impact, waking up at night so different somewhat #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I agree that predicting outcome was not the objective of developing the #CTS6, but seemingly the two have a lot in common despite the different focus. #jhsjc
Brent Graham @BgTalkinman to @whammert:
Symptoms including nocturnal symptoms are key components of the #CTS6 and a high probability of #CTS can be assigned even with few physical exam findings. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
agreed. We thought so too. I suspect if a hypothetical trial was done with all patients getting CTR with high and low CTS 6 scores without further judgement if actually have CTS then it would predict outcomes in that those with actual CTS would respond. #jhsjc
Warren @whammert to @BgTalkinman:
I agree, but all the others add to the CTS -6 score, but not sure it makes a difference after a certain point – night time and predominant median nerve distribution seem to be the most important. #jhsjc
Brent Graham @BgTalkinman:
There was a wide range of #CTS6 scores but not many pts with a low score so not many with an atypical presentation. What effect of any might that have had on the observation of little correlation? #jhsjc
Warren @whammert to @BgTalkinman:
With thenar weakness being more subjective and less likely to correlate with outcomes #jhsjc
Brent Graham @BgTalkinman to @whammert:
Both of those are important components of #CTS6. My feeling is that the binary nature of the judgements for the components of the #CTS6 might partly explain this. #jhsjc
Warren @whammert to @BgTalkinman:
I think more important for being confident in the diagnosis than patients perception of outcome. I agree that this is binary. #jhsjc
Brent Graham @BgTalkinman to @whammert:
Thenar weakness is heavily weighted in the #CTS6 but not commonly encountered so a the diagnosis can have a high probability of the diagnosis without that. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
Do you think a low #CTS6 score might correlate better with poor results? #jhsjc
Warren @whammert @BgTalkinman:
For CTS -6, my impression is thenar weakness, tinel’s are more variable and 2PD not as commonly tested, but you can get the 12.5 without those. I am not sure there is a difference in a score of 14 or 22? #jhsjc
Brent Graham @BgTalkinman to @whammert:
Agreed! That’s why I ask @RPCalfeeSTL if correlation might be higher for low scores and poor outcomes. #jhsjc
Warren @whammert to @BgTalkinman:
I think lower score with night time awakening can still have good improvement (B CTQ) – more so that a score over 12.5 without night time awakening. #jhsjc
Brent Graham @BgTalkinman:
The CTS-6 doesn’t make recommendations about treatment. The fact that its output is a probability of CTS, makes it flexible – the probability threshold beyond which treatment is recommended can be adjusted according to the setting, eg a higher probability for #WC cases. #jhsjc
Assuming that there is a link between accuracy of diagnosis and treatment outcome, are there settings in which the CTS-6 would be more likely to be predictive of outcome? #jhsjc
Warren @whammert to @BgTalkinman:
I think the early outcome hinges on night time symptoms. While you can have CTS without this, I think it takes longer to see the outcomes and constant day numbness often takes longer to resolve and night is almost always immediate #jhsjc
Chris Grandizio @ChrisGrandizio to @whammert:
It would be interesting to look at a larger sample of the small group without nighttime awakening on CTS-6 #jhsjc
Brent Graham @BgTalkinman:
I will answer my own question – not necessarily! For example, in #WC cases the probability for an accurate diagnosis may be very high and yet the result may still be poor bc of the complex variables involved in managing that kind of case. #jhsjc
David Ring @DrDavidRing:
It might help to have separate measures of illness (e.g. Night time wakening) and disease (loss of sensibility). #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing
In the end the #CTS6 was supposed to help estimate a probability of a specific diagnosis, ie #CTS. Obviously the response to any treatment following that diagnosis is a separate issue and this study seems to show that to a certain extent. #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other study, another one about diagnosis but with a focus on reliability and treatment recommendations. #jhsjc
The main findings of this study were that agreement on the Geissler grade was, at best, fair and didn’t improve appreciably with access to both radiocarpal and midcarpal views. #jhsjc
Recommendation for surgery was associated with having both arthroscopic views. #jhsjc
The authors conclude that agreement doesn’t improve with more information but having the mid-carpal view led to a more frequent recommendation for surgery, even though reliability of Geissler classification, presumably the basis for recommending surgery, was limited. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Well people with atrophy, weakness, and static numbess say “well thanks for nothing.” So there is a real advantage to separating severe from less severe median neuropathy. #jhsjc
Warren @whammert to @BgTalkinman:
I think arthroscopy is something ones understands more with experience and the “feel” as authors point out, so harder to evaluate by looking at videos. #jhsjc
David Ring @DrDavidRing to @whammert and @BgTalkinman:
The energy behind this study (Dr. Kraan) deserves our admiration. He was humble enough to put his uncertainty about people with wrist pain and the role of wrist arthroscopy into focus. The fact that we have no agreement on pathology even with a direct look is humbling.
Warren @whammert to @DrDavidRing:
definitely ! #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I don’t disagree! Choice of treatment requires a different set of considerations. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
all good points #jhsjc
Brent Graham @BgTalkinman to @whammert and @DrDavidRing:
What effect does that have on these results – the use of video? #jhsjc
Brent Graham @BgTalkinman:
The authors conclude that more information, i.e., from a mid-carpal arthroscopy together with that from a radiocarpal arthroscopy, could result in “the potential for a larger amount of diagnostic information to add diagnoses and treatments without improving health”. #jhsjc
An alternative interpretation would be having more information allows for a better assessment of pathology. The reliability of the extent of SLIL pathology was not improved by having that additional information – and was overall limited – which view is the right one? #jhsjc
Warren @whammert to @BgTalkinman:
I think the results might be dependent on arthroscopy experience level – maybe if we graded as is done in some of the European papers and based on arthroscopy experience rather than hand surgery experience, there would be more consistency in diagnosis #jhsjc
David Ring @DrDavidRing to @BgTalkinman and @whammert:
Most of us think: “what’s the harm of taking a look.” The fact that diagnosis can cause harm. And the fact that harm can be financial, psychological, and harmful is counter intuitive. Check this out: https://www.nejm.org/doi/full/10.1056/NEJMsr1905447 #jhsjc
Warren @whammert to @BgTalkinman:
There are times when mid carpal adds to understanding but not diagnosis – if big gap from RC joint, mid carpal doesn’t help with diagnosis, but can asses cartilage, LT interval… #jhsjc
David Ring @DrDavidRing to @whammert:
Consider the possibility that being more “experienced” is akin to being more “indoctrinated.” I find that the less experienced among us often have a more dispassionate, humanistic, balanece mindset. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I would say it’s more basic than that. If there is poor agreement on what we are treating then results can’t help but be equally variable, all the other potential harms aside. #jhsjc
Brent Graham @BgTalkinman:
Poor reliability = variable results of treatment is a truism just about everywhere it’s been studied. #jhsjc
Warren @whammert to @DrDavidRing:
I agree more “experienced” is more likely to find more diagnoses #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
It’s hard to understand and believe that less information can be healthier. And there are so many examples where less is more. https://pubmed.ncbi.nlm.nih.gov/32303454/ #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I guess another way of framing that is that when all you’ve got is a hammer (or a specific diagnosis), everything looks like a nail. #jhsjc
Hypocritus mediocritus @homomediocritus to @BgTalkinman and @DrDavidRing:
why hunt a pathology if we don’t have a proven effective treatment for it? Surgery for SL issues is imperfect and imho best reserved for gross instability in a patient who understands the imperfections of intervention. Chasing milder SL pathology makes zero sense for me.
Brent Graham @BgTalkinman to @homomediocritus and @DrDavidRing:
I think it depends on the situation. Patients should make choices when presented with valid and reliable information. The problem is that, as the study shows, the information is not necessarily reliable, so it’s validity is somewhat moot. Therein lies the problem. #jhsjc
Hypocritus mediocritus @homomediocritus to @BgTalkinman and @DrDavidRing:
that’s true – however moving on from that, if we accept our intervention is far from reliable and effective then it makes diagnosis somewhat less important……
Brent Graham @BgTalkinman to @homomediocritus and @DrDavidRing:
I don’t agree. The interventions ARE reliable and effective when used in the correct situation, starting with an accurate diagnosis. When there is confusion about the diagnosis obviously, treatment isn’t effective. The correct diagnosis isn’t “less important” – it’s paramount.
Hypocritus mediocritus @homomediocritus to @BgTalkinman and @DrDavidRing:
it depends though doesn’t it……if you have no effective intervention for the spectrum of the diagnoses, then diagnosis isn’t very useful however good, for example in much back pain treatment…..
Brent Graham @BgTalkinman to @homomediocritus and @DrDavidRing:
Establishing an accurate diagnosis to identify a prognosis is still important even if there isn’t effective treatment.
Hypocritus mediocritus @homomediocritus to @BgTalkinman and @DrDavidRing:
if one has good evidence for prognosis………which I don’t think we do for SL insufficiency
Brent Graham @BgTalkinman to @homomediocritus and @DrDavidRing:
I think it depends on the situation. Patients should make choices when presented with valid and reliable information. The problem is that, as the study shows, the information is not necessarily reliable, so it’s validity is somewhat moot. Therein lies the problem. #jhsjc
Brent Graham @BgTalkinman:
What would you say toi more information that was reliable? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
“You have wrist pain. I have a scope. Most wrist pain is idiopathic and benign. How about, “pain is disconcerting. It’s difficult. We’ll find a way.” #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
In other words, if the reliability of the two views was much higher than the radiocarpal view only, would that increased and reliable information be justified in resulting in more recommendations for treatment? #jhsjc
Warren @whammert to @DrDavidRing:
Our culture and legal system doesn’t go along with less is better – it seems to be set up to penalize those with less information. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Reliable and accurate information is helpful. There is, in the end, a need to match that with what matters most to a person, independent of common misconceptions. An ethical imperative. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
I agree with that entirely and that is exactly why papers like this are important. The way forward is to improve the reliability of our diagnoses AND our treatments. #jhsjc
Warren @whammert to @DrDavidRing:
And I am not saying you are wrong – I agree that over diagnosis can be a problem, but society as a whole doesn’t seem to like that approach. #jhsjc
Brent Graham @BgTalkinman to @whammert:
Do you mean that what people want are firm diagnoses? If so, I agree that’s what they want but we have a responsibility to tell them that uncertainty is almost always inevitable as unpalatable as they might find that – because it’s true. #jhsjc
Warren @whammert to @BgTalkinman:
Yes – many people want a firm diagnosis and if they don’t get one or what they want, they start doctor shopping until they do. #jhsjc
Avi Giladi @theaviram to @whammert:
that may be true. but who is responsible for them making that decision? #jhsjc
Warren @whammert to @theaviram:
Ultimately the patient unless the doc says to get another opinion. #jhsjc
Brent Graham @BgTalkinman to @whammert:
At the risk of seeming harsh, that’s their problem and not something I feel a need to pander to. If they can’t understand that the world is complicated and that’s why there is uncertainty, I don’t really get what our role is. Maybe that’s just me. #jhsjc
Brent Graham @BgTalkinman:
In light of these findings, what is the role for diagnostic arthroscopy in the very commonly encountered setting of wrist pain, tenderness in the scapholunate area and negative plain radiographs? I would like to hear from everyone on that question! #jhsjc
Hypocritus mediocritus @homomediocritus to @BgTalkinman:
Close to zero. Get an MRI. Then assess history/exam and MRI results. There’s little role for arthroscopy as fishing for common pathology of unknown significance to patients can do much much harm.
Warren @whammert to @BgTalkinman:
I usually have an MRI prior to offering a scope – If MRI completely normal, then unlikely I will find anything important on the scope and less helpful. If MRI shows something – even degenerative, debridement can be helpful. #jhsjc
Brent Graham @BgTalkinman to @whammert:
MRI -that’s another can of worms! #jhsjc
Avi Giladi @theaviram to @whammert and @BgTalkinman:
Agreed, the patient can decide to go elsewhere. I think it is on us to make sure that doesnt change how we decide on/deliver care. #jhsjc
Chris Grandizio @ChrisGrandizio to @theaviram:
agreed! #jhsjc
Warren @whammert to @BgTalkinman:
there are many levels of sophistication for patients and some understand more than others #jhsjc
Brent Graham @BgTalkinman to @whammert and @theaviram:
Maybe I’m just too old school but I always feel that in my practice setting the buck stops with me – I give the best answers I can and make clear the uncertainty and if the pts can’t -or won’t-accept that, I don’t see what other responsibility I have. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
That is very true. We have a responsibility to be clear and honest, not give them what they ask for if it isn;t in their best interest. #jhsjc
Warren @whammert to @BgTalkinman:
I don’t think you have more responsibility that that – but in the world where press ganey scores rule and patient satisfaction is relevant (and not always representative of good medicine) we have to walk a fine line #jhsjc
Brent Graham @BgTalkinman to @whammert:
To me that just means more time required explaining it using words they can understand. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman and @theaviram:
Agree with give best advice possible even when it isn’t what people want to hear. #jhsjc
Brent Graham @BgTalkinman to @whammert:
I guess we will just have to disagree on that one. #jhsjc
Brent Graham @BgTalkinman:
We are past our time but hopefully the conversation continues! We are back tomorrow afternoon and then next month Nov 8/9. Thanks to everyone for participating! #jhsjc
Brent Graham @BgTalkinman:
Welcome to our October session, Eurozone edition! I know that the @BSSH meeting is taking place and so some people who might normally participate in this session may be unavailable. I will monitor for the next hour and happily discuss either of the 2 featured articles. #jhsjc
Let’s start with the study looking at whether the @CTS6 predicts outcome follwing a #CTR. #jhsjc
Brent Graham @BgTalkinman:
@ryckiewade tells me that wrist arthroscopy is not necessarily a common procedure in Europe. It hasn’t figured much in my own practice however, this paper brings up some interesting issues related to diagnostic reliability and its relationship to treatment recommendations. #jhsjc
The objective of the study was to determine if the CTS-6, a diagnostic scale, could predict the outcome of carpal tunnel release (CTR) as measured by the Boston Carpal Tunnel Questionnaire (BCTQ). #jhsjc
The authors justify that goal by pointing out that the CTS-6 comprises symptoms and physical examination findings that CTR seeks to address., which is very true, so it might be expected to correlate with post-treatment changes on the #BCTQ, a status instrument. #jhsjc
The study design was a prospective cohort of 118 patients who underwent open CTR. There were substantial changes in the BCTQ at 6 months following treatment, especially in terms of symptoms, which were improved in 94% of patients. #jhsjc
Pre-operative CTS-6 scores did not correlate with changes in the BCTQ scores, nor were they correlated with Decision Regret Scale results or satisfaction. #jhsjc
The BCTQ measures condition status and treatment effect because treatment affects the condition status. The CTS-6 measures symptoms and physical examination findings, which also reflect condition status. Why wouldn’t the CTS-6 predict the BCTQ following CTR? #jhsjc
The mean #CTS6 score for the group was >19, signifying a very high probability of CTS (range 7-26); 5 pts had a score of less than 12, IOW, not many patients with less common presentations. Should that have any effect on the correlation of #CTS6 and post-treatment #BCTQ? #jhsjc
In other words, is there a potential predictive role if the CTS-6 is below a certain threshold? Would it be more likely to predict a poor outcome with a low score, suggesting a lower probability that #CTS was an accurate diagnosis? #jhsjc
I will answer my own question: I think the #CTS6 might correlate with outcomes in that instance bc diagnostic accuracy is a major factor determining treatment success. Therefore, a low pre-rx #CTS6 would be expected to result in a smaller #BCTQ change after treatment. #jhsjc
The #CTS6 doesn’t make recommendations about treatment and the fact that its output is a probability, it is inherently flexible in that the probability threshold beyond which treatment is recommended can be adjusted according to the setting. #jhsjc
For example, the threshold for recommending treatment could be set higher for a patient with a workers’ compensation claim – presumably that would be a stronger indication of an accurate diagnosis and possibly a greater likelihood of treatment success in that setting. #jhsjc
Assuming that there is a link between accuracy of diagnosis and treatment outcome, are there settings in which the CTS-6 would be more likely to be predictive of outcome? #jhsjc
I will wrap it up here. Feel free to comment further and use the #jhsjc hashtag. We will return Nov 9.
