What are the treatment options for carpal tunnel syndrome?

Treatment Options for Carpal Tunnel Syndrome

Surgical treatment (carpal tunnel release) is the most effective definitive treatment for carpal tunnel syndrome, while conservative measures like wrist splinting and steroid injections should be considered as first-line options for mild to moderate cases. 1

Diagnosis and Assessment

• Carpal tunnel syndrome is primarily diagnosed through clinical evaluation combined with electrophysiologic studies
• Key symptoms include numbness, tingling, and pain in a median nerve distribution
• In selected circumstances, ultrasound or MRI without contrast may be appropriate for imaging 1

Conservative Treatment Options

Wrist Splinting

• Most effective initial conservative treatment 2
• Advantages: availability, low cost, good patient tolerance, simplicity, minimal complications
• Recommended parameters:
  • Immobilize wrist in neutral position or slightly extended (0-15 degrees)
  • Initially use at night for several weeks
  • During symptom exacerbation, can also be used during day activities that worsen symptoms
  • No significant differences between rigid vs. soft orthoses or custom vs. traditional orthoses 2

Steroid Injections

• Local steroid injection into the carpal tunnel is an effective option 3
• Can be used in combination with wrist splinting
• Provides temporary relief but long-term effectiveness is limited to about 10% of patients 4
• Patients with symptom duration less than 3 months and absence of sensory impairment are more likely to have lasting response 4

Other Conservative Options

• Oral steroids or ultrasound therapy may be considered 3
• Heat therapy is not recommended 3

Surgical Treatment

Indications for Surgery

• When conservative treatment fails to resolve symptoms within 2-7 weeks 3
• Early surgery is an option with clinical evidence of median nerve denervation 3
• When patient elects for surgical intervention based on symptom severity or lifestyle impact

Surgical Procedure

• Complete division of the flexor retinaculum (transverse carpal ligament) is recommended 3
• Can be performed through open or endoscopic approaches
  • Endoscopic and open release are similarly effective in relieving symptoms and improving function
  • Endoscopic release may offer functional benefits for grip strength and earlier return to work 1
  • Endoscopic approach may have increased risk of nerve injury compared to open release 1

Post-Surgical Care

• Wrist immobilization is not recommended after routine carpal tunnel surgery 3
• Preoperative antibiotics are optional 3

Treatment Algorithm

1. Initial Presentation (Mild to Moderate Symptoms)

   • Begin with wrist splinting (neutral position, nighttime use)
   • Consider local steroid injection
   • Trial for 2-7 weeks

2. If Symptoms Persist After Conservative Treatment

   • Proceed to surgical evaluation
   • Complete division of the flexor retinaculum (carpal tunnel release)

3. Special Considerations

   • Patients with median nerve denervation: consider early surgical intervention
   • Patients with very short duration of symptoms (<3 months): may have better response to conservative treatment 4

Potential Complications

• Incomplete division of the transverse carpal ligament
• Nerve injury (higher risk with endoscopic approach)
• Tendon adhesions
• Scar tenderness
• Pillar pain
• Recurrence of symptoms 5

Outcomes Assessment

• For research purposes, instruments such as the Boston Carpal Tunnel Questionnaire and the Disabilities of the Arm, Shoulder, and Hand questionnaire are suggested to assess patient responses to treatment 3

Long-term Outcomes

• Approximately 43% of patients may be successfully treated with splint treatment alone over a 36-month follow-up period 6
• Surgical treatment provides more reliable and durable symptom relief compared to conservative measures 1