Threshold

Norfolk and Waveney Integrated Care Board (ICB) will fund treatment for Carpal Tunnel Syndrome (CTS) provided the following guidelines have been used in the referral and decision to treat:

This condition is a clinical diagnosis defined by symptoms in the distribution of the median nerve (palmar surface of the thumb and radial 3 digits). These include positive symptoms of pain and paraesthesia or negative symptoms of sensory loss and thenar muscle weakness.  Management and the decision to refer is based on the severity of symptoms and the likely benefits of appropriate intervention. It is a heterogenous group of patients, but they can be loosely considered in the following categories:

a) Patients with mild intermittent positive symptoms:

A trial of conservative management should be considered. Splints, nerve glide exercises, lifestyle/ workplace modification and/or if available, a steroid injection. Persistent or worsening symptoms over three months would warrant onward referral.

b) Patients with moderate intermittent positive symptoms and/or early signs of negative symptoms.

This represents the majority of CTS patients. Neurophysiological assessment of severity can be invaluable in determining the best treatment and should be considered prior to referral.

c) Patients with severe debilitating positive symptoms.

These patients are being woken with pain and paraesthesia nightly and may have trouble working. Treatment for this group should be commenced promptly without the need for prior neurophysiology. Steroid injection, if available, is an excellent way to confirm the diagnosis and commence treatment. Indeed, where there is a complete and sustained response to steroid injections onward referral may not be necessary.

Where there is little or no response to steroid injection, this calls the diagnosis into question. In this event, neurophysiology would be indicated as would consideration of other possible underlying causes such as cervical nerve root compression.

d) Patients with predominantly negative symptoms.

Complete sensory loss and/or motor dysfunction suggests end-stage disease. NCS is indicated to assess the extent of axonal loss and to establish if any reversible component remains. Established end-stage disease with negative symptoms will tend not improve with treatment and onward referral is discouraged. This should be fully discussed with the patient to inform them that there would be no clinical benefit for treatment at this stage.

NB: In all cases, if Nerve Conduction Studies have been requested, kindly review them prior to referral and enclose the results

CASES FOR INDIVIDUAL CONSIDERATION

On a case to case basis, patients might be eligible for intervention, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request.