From the Guidelines
Management of carpal tunnel syndrome should begin with conservative approaches, including wrist splinting, anti-inflammatory medications, and activity modification, before considering surgical intervention, as these methods can effectively relieve symptoms and improve functional status, as suggested by the most recent and highest quality study 1. The initial treatment includes wrist splinting at night to maintain a neutral position, which reduces pressure on the median nerve. Over-the-counter anti-inflammatory medications like ibuprofen (400-600mg three times daily) or naproxen (250-500mg twice daily) can help reduce inflammation and pain. Activity modification is essential, including ergonomic adjustments at work, taking regular breaks from repetitive activities, and avoiding positions that exacerbate symptoms.
- Corticosteroid injections (typically methylprednisolone 20-40mg with lidocaine) into the carpal tunnel can provide temporary relief for moderate symptoms, usually lasting several weeks to months.
- Physical therapy focusing on nerve gliding exercises and stretching may also help. For persistent or severe cases unresponsive to conservative treatment after 6-12 weeks, surgical decompression (carpal tunnel release) is recommended to cut the transverse carpal ligament and relieve pressure on the median nerve, with both open and endoscopic releases being effective, although endoscopic release may have functional benefits over open release, as indicated by a recent umbrella review of level 1 evidence 1. Early treatment is important as prolonged nerve compression can lead to permanent nerve damage, muscle atrophy, and persistent symptoms even after treatment. In terms of diagnostic imaging, clinical evaluation combined with electrophysiologic studies is the primary method for diagnosing carpal tunnel syndrome, with further imaging such as wrist US or MRI without contrast being appropriate in selected circumstances, as suggested by recent guidelines 1.
From the Research
Management of Carpal Tunnel Syndrome
The management of carpal tunnel syndrome (CTS) involves a combination of pharmacotherapy, conservative treatments, and surgery. The goal of therapy for CTS is to improve symptoms and reduce signs of the disease, as well as prevent progression and loss of hand function 2.
Conservative Treatments
Conservative treatments for CTS include:
- Non-steroidal anti-inflammatory drugs (NSAIDs) 2, 3, 4
- Local and systemic corticosteroids 2, 5, 4
- Diuretics 2, 3, 6
- Pyridoxine (Vitamin B6) 2, 6
- Splinting and activity modification 2, 5, 4, 6
- Ultrasound therapy 6
- Yoga 6
- Carpal bone mobilisation 6
Surgical Treatment
Surgery is considered the definitive treatment for CTS, and is often recommended for patients who do not respond to conservative treatments 2, 5. Surgical treatment involves the release of the carpal tunnel to relieve pressure on the median nerve.
Effectiveness of Treatments
Studies have shown that conservative treatments can provide significant short-term benefit for patients with CTS 5, 4, 6. However, the long-term effectiveness of these treatments is variable, and surgery may be necessary for patients with persistent symptoms 2, 5. The choice of treatment depends on the severity of symptoms, the duration of symptoms, and the presence of underlying medical conditions 5, 4.
Predictive Factors for Treatment Outcome
Studies have identified several predictive factors for treatment outcome, including:
- Duration of symptoms: Patients with shorter duration of symptoms are more likely to respond to conservative treatments 5
- Presence of sensory impairment: Patients with sensory impairment are less likely to respond to conservative treatments 5
- Presence of thenar wasting: Patients with thenar wasting are less likely to respond to conservative treatments 5