Background 

Accurately distinguishing the severity of pathophysiology from the level of symptom intensity and incapability is a foundation of effective treatment strategies under the biopsychosocial paradigm of illness. With respect to idiopathic median neuropathy at the carpal tunnel (the symptoms and signs of which are referred to as carpal tunnel syndrome), surgeons who are more likely to recommend surgery based on the magnitude of symptoms and incapability rather than the severity of neuropathy may be underappreciating and undertreating mental health opportunities and overtreating mild, and on occasion unmeasurable, disease. A survey-based experiment that randomizes elements of the patient presentation can help determine the relative influence of magnitude of incapability on ratings of pathology severity.

Question/purpose 

What factors are associated with severity rating of idiopathic median neuropathy at the carpal tunnel on an 11-point ordinal scale?

Methods 

One hundred eight hand and wrist members of the Science of Variation Group (among approximately 200 participants who complete at least one survey-experiment a year related to the upper extremity on average) reviewed seven scenarios of fictional median neuropathy with seven randomized variables: age, gender, limitations of daily activity (incapability), Tinel and Phalen test results, duration of numbness episodes, prevention of numbness with nocturnal splint immobilization, constant numbness, and weakness of palmar abduction. Participants had a mean age of 51 ± 10 years, 90% (97 of 108) were men, and 74% (80 of 108) were subspecialized in hand surgery. Surgeons were asked to rate the severity of idiopathic median neuropathy at the carpal tunnel on a on an 11-point ordinal scale. Factors associated with rated severity were sought in multilevel ordered logistic regression models. Fifteen surgeons did not complete all of their assigned randomized scenarios, resulting in a total of 675 ratings.

Results 

After controlling for potentially confounding variables such as magnitude of incapability, factors associated with severity rating on the 11-point ordinal scale included palmar abduction weakness (odds ratio 11 [95% confidence interval 7.7 to 15]), longer duration of symptom episodes (OR 4.5 [95% CI 3.3 to 6.2]), nocturnal numbness in spite of splint immobilization (OR 3.2 [95% CI 2.3 to 4.3]), constant numbness (OR 2.5 [95% CI 1.9 to 3.4]), positive Tinel and positive Phalen test results (OR 2.2 [95% CI 1.6 to 2.9]), and older age (OR 1.6 [95% CI 1.2 to 2.1]).

Conclusion 

Our results suggest that surgeons rate the severity of idiopathic median neuropathy at the carpal tunnel based on evidence of worse pathophysiology and are not distracted by greater incapability.

Clinical Relevance 

Surgeons who consider greater incapability as an indication of more severe pathology seem to be practicing outside the norm and may be underappreciating and undertreating the unhelpful thoughts and feelings of worry or despair that consistently account for a notable amount of the variation in symptom intensity and magnitude of incapability.

中文翻译：

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外科医生对腕管特发性正中神经病变严重程度的评级不受失能程度的影响

背景 

准确区分病理生理学的严重程度与症状强度和丧失能力的水平是疾病生物心理社会范式下有效治疗策略的基础。对于腕管特发性正中神经病变（其症状和体征称为腕管综合征），外科医生更有可能根据症状的严重程度和无能力而不是神经病变的严重程度来推荐手术。低估和治疗心理健康机会，过度治疗轻微的、有时无法测量的疾病。基于调查的实验将患者表现的元素随机化，可以帮助确定丧失能力程度对病理严重程度评级的相对影响。

问题/目的 

哪些因素与腕管特发性正中神经病变（按 11 点顺序评分）的严重程度评级相关？

方法 

变异科学组的 108 名手部和腕部成员（其中平均每年至少完成一次与上肢相关的调查实验的大约 200 名参与者）审查了 7 个虚构的正中神经病场景，其中包括 7 个随机变量：年龄、性别、日常活动限制（无能力）、Tinel 和 Phalen 测试结果、麻木发作持续时间、通过夜间夹板固定预防麻木、持续麻木和手掌外展无力。参与者的平均年龄为 51 ± 10 岁，90%（108 人中的 97 人）是男性，74%（108 人中的 80 人）是手外科专业人士。外科医生被要求按照 11 点顺序等级来评估腕管特发性正中神经病变的严重程度。在多级有序逻辑回归模型中寻找与评级严重程度相关的因素。15 名外科医生没有完成所有分配给他们的随机场景，总共得到 675 个评分。

结果 

在控4.5 [95% CI 3.3 至 6.2]），尽管有夹板固定但夜间麻木（OR 3.2 [95% CI 2.3 至 4.3]），持续麻木（OR 2.5 [95% CI 1.9 至 3.4]），Tinel 阳性和阳性Phalen 测试结果（OR 2.2 [95% CI 1.6 至 2.9]）和年龄（OR 1.6 [95% CI 1.2 至 2.1]）。

结论 

我们的结果表明，外科医生根据更糟糕的病理生理学证据来评估腕管特发性正中神经病变的严重程度，并且不会因更大的无能力而分心。

临床相关性 

那些认为更严重的无能是更严重病理的征兆的外科医生似乎在正常范围之外进行实践，并且可能低估和低估了无用的担忧或绝望的想法和感觉，这些想法和感觉一直是症状强度和严重程度变化的显着原因。无能力。