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Wide Awake vs Sedation in Carpal Tunnel Surgery: A Qualitative Study on Patient Decision Making and Pain Perceptions
Samuel R Nofsinger, MA, Bryce Fletcher, BS, Julia AV Nuelle, MD, Sebastien Lalonde, MD; Daniel London, MD
University of Missouri, Columbia, MO
IntroductionWe performed a prospective qualitative study to determine factors that play a role in patient decision-making between local anesthesia (LA) versus sedation in the operating room (OR) for carpal tunnel surgery. In addition, we hypothesized that patient pain perceptions would influence this choice.
Materials and Methods15 LA patients and 15 OR patients were interviewed before and after undergoing carpal tunnel surgery. Interview transcripts were analyzed using constant comparative methodology to identify common themes. Perceptions of pain were measured by the Pain Catastrophizing Scale (PCS), Pain Sensitivity questionnaire (PSQ), and Pain Self-Efficacy Questionnaire (PSEQ). Groups were compared by t-tests.
Results We identified primary drivers in decision-making between LA and OR
(Table 1). Illustrative quotes are provided in
Table 2. Patient preferences for LA were influenced by a desire to avoid anesthesia, the expedience of the experience, and the ability to drive afterward. Primary drivers for sedation were diverse and centered on avoiding wakefulness rather than actively choosing sedation, usually secondary to feelings of anxiety or past medical experiences. An internal desire for control, or lack thereof, emerged as a key differentiating domain between the groups. LA patients valued maintaining control throughout the procedure, expressing discomfort with the time-slippage and loss of agency associated with sedation. They preferred the ability to remain aware and engaged, viewing their presence as a form of quality control. In contrast, OR patients generally valued the freedom afforded by sedation, favoring sedation to dissociate from the experience and relinquish control. Several patients were concerned about unintended movement during surgery and viewed sedation as a means to minimize perceived personal responsibility for the outcome. In both groups, decision-making involved a complex interplay of conscious (e.g. primary drivers) and unconscious factors (e.g. desire for control, perception of pain for the procedure). Patients felt adequately informed without the need for additional information. Furthermore, anecdotal experiences of others and the physician-patient relationship were not determining factors in decision-making. There was no significant difference between the groups' scores on the PCS (21.1 v 25.1, p=0.45), PSQ (52.5 v 61.1, p=0.35), or PSEQ (37.4 v 41.8, p=0.32).
Conclusions - Patients chose LA for the ability to avoid anesthesia and logistical simplicity.
- Patients chose the OR to avoid wakefulness.
- Internal desire for control was a distinguishing domain in decision-making.
- Pain perceptions were not significantly different between groups.
- Knowledge of these drivers could influence pre-operative conversations and potentially impact patient choices.
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