From the Guidelines
Diagnosing carpal tunnel syndrome should start with a clinical evaluation combined with electrophysiologic studies, and further imaging is usually not needed, but in selected circumstances, either wrist US or MRI without contrast may be appropriate. The diagnosis and management of carpal tunnel syndrome involve a combination of clinical assessment and diagnostic tests. According to the most recent guidelines 1, when there is concern for carpal tunnel syndrome (CTS) in the setting of chronic wrist pain with normal or indeterminate radiographs, US area of interest or MRI area of interest without IV contrast may be appropriate as the next imaging study.
Diagnostic Approach
- Clinical evaluation, including Tinel's test and Phalen's test, is crucial for diagnosing carpal tunnel syndrome.
- Electrodiagnostic studies like nerve conduction studies and electromyography provide objective confirmation of the diagnosis.
- Imaging studies such as wrist US or MRI without contrast may be considered in selected cases where the diagnosis is unclear or when further evaluation is needed.
Management
- Initial treatment is conservative, starting with wrist splinting at night in a neutral position for 4-6 weeks.
- Anti-inflammatory medications such as ibuprofen or naproxen can reduce inflammation.
- Corticosteroid injections into the carpal tunnel provide temporary relief for moderate cases.
- Activity modifications and ergonomic workplace adjustments are essential components of management.
- For severe or persistent cases not responding to conservative measures after 6-12 weeks, surgical decompression through carpal tunnel release is recommended, which can be performed as open surgery or endoscopically with similar outcomes, as supported by the guidelines 1 and updated recommendations 1.
From the Research
Diagnostic Tests for Carpal Tunnel Syndrome
- The Phalen test and Tinel sign are commonly used provocative maneuvers to diagnose carpal tunnel syndrome (CTS), but they have varying sensitivity and specificity 2.
- Thenar atrophy is a late finding and highly specific for CTS 2.
- Electrodiagnostic studies, such as nerve conduction studies, can confirm the diagnosis of CTS, exclude other causes, and gauge severity for surgical prognosis 2.
- The forearm elevation-compression test (FECT) is a novel test that can be used for bedside diagnosis of CTS, with a positive predictive value of 87.5% 3.
- Ultrasonography (US) can be used as a diagnostic tool in the investigation of patients with CTS, and can improve the diagnostic ability of CTS by measuring the median nerve area (MNA) 4.
- A combination of clinical tests, including Tinel, Phalen, reverse Phalen, carpal compression, and vibration tests, can be used to diagnose CTS, with the Tinel test being the most specific and the vibration test being the most sensitive 5.
Treatment Options for Carpal Tunnel Syndrome
- Over-the-counter analgesics, such as nonsteroidal anti-inflammatory drugs and acetaminophen, have not shown benefit for CTS 2.
- Nonsurgical treatments, such as splinting or local corticosteroid injections, can be effective for patients with mild to moderate CTS 2.
- Night-only splinting is as effective as continuous wear, and a neutral wrist splint may be more effective than an extension splint 2.
- Corticosteroid injections provide slightly greater improvement of symptoms compared with splinting at 6 weeks, with similar outcomes at 6 months 2.
- Acupuncture and electroacupuncture therapy may improve symptoms and aid nerve repair, and can be suggested as a safe and suitable therapeutic method in CTS 6.
- Surgical decompression is recommended for patients with severe CTS, including objective weakness or sensory deficits, with endoscopic and open carpal tunnel release techniques being equally effective 2.