What are the management options for carpal tunnel syndrome?

From the Guidelines

Carpal tunnel syndrome management should prioritize surgical decompression for persistent or severe symptoms, as it has been shown to relieve symptoms significantly better than non-surgical treatment, despite being associated with more complications 1.

Management Options

The management of carpal tunnel syndrome involves a range of options, from conservative approaches to surgical intervention. Initial treatment includes:

• Wrist splinting, particularly at night, to maintain a neutral wrist position and reduce pressure on the median nerve
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen to help reduce inflammation and pain
• Corticosteroid injections into the carpal tunnel, typically methylprednisolone with lidocaine, to provide temporary relief for moderate symptoms
• Activity modification, including ergonomic adjustments at work, taking regular breaks from repetitive activities, and avoiding extreme wrist positions
• Physical therapy exercises focusing on nerve gliding and stretching may help some patients

Surgical Intervention

For persistent or severe symptoms, surgical decompression through carpal tunnel release is highly effective, with either open or endoscopic techniques showing good outcomes 1. Surgery involves cutting the transverse carpal ligament to relieve pressure on the median nerve and can be performed under local anesthesia as an outpatient procedure. The choice between conservative and surgical management depends on symptom severity, duration, and the presence of motor weakness or muscle atrophy, which may indicate the need for earlier surgical intervention.

Diagnostic Evaluation

Suspected carpal tunnel syndrome is diagnosed by clinical evaluation combined with electrophysiologic studies, and further imaging is usually not needed 1. However, in selected circumstances, either wrist US or MRI without contrast may be appropriate.

Key Considerations

• The effectiveness of endoscopic and open release in relieving symptoms and improving functional status is similar, although endoscopic release may have functional benefits over open release with regards to return to work and improved grip strength 1
• The risk of nerve injury is increased with endoscopic release compared to open release 1
• The quality of evidence for these findings is generally low to very low, highlighting the need for further high-quality research in this area 1

From the Research

Management Options for Carpal Tunnel Syndrome

• Conservative treatment may be offered initially to patients with mild to moderate carpal tunnel syndrome, including options such as:
  • Splinting: may provide little or no benefits in symptoms in the short term, but night-time splinting may result in a higher rate of overall improvement 2
  • Corticosteroids: local corticosteroid injection can provide relief for more than one month and delay the need for surgery at one year 3
  • Physical therapy: may be beneficial, but evidence is limited 4
  • Therapeutic ultrasound: may be beneficial, but evidence is limited 4
  • Yoga: may reduce pain and improve symptoms 4
• Nonsteroidal anti-inflammatory drugs, diuretics, and vitamin B6 are not effective therapies 3, 4
• Surgical decompression may be offered to patients with severe carpal tunnel syndrome or whose symptoms have not improved after four to six months of conservative therapy 3, 5
• Endoscopic and open techniques are equally effective, but patients return to work an average of one week earlier with endoscopic repair 3

Considerations for Treatment

• The effectiveness and duration of benefit from non-surgical treatment for carpal tunnel syndrome remain unknown 4
• Electrodiagnostic studies may be performed to confirm a diagnosis of carpal tunnel syndrome or to obtain a baseline before surgical treatment 3, 5
• Patients with recalcitrant carpal tunnel syndrome may have perineural fibrosis that tethers the median nerve 5
• The clinical relevance of small differences with splinting is unclear, but small effects could justify its use, particularly when patients are not interested in having surgery or injections 2