What is the treatment for carpal tunnel syndrome?

Treatment for Carpal Tunnel Syndrome

For carpal tunnel syndrome, a stepwise approach starting with conservative measures for mild to moderate cases and progressing to surgical intervention for severe or refractory cases is recommended. 1

Diagnosis

• Diagnosis is primarily clinical based on:
  • Pain and paresthesia in median nerve distribution
  • Provocative tests (Phalen's maneuver, Tinel's sign)
  • Thenar atrophy (late finding, highly specific) 1
• Electrodiagnostic studies are indicated for:
  • Atypical presentations
  • Excluding other causes
  • Gauging severity for surgical planning 1

Treatment Algorithm

Step 1: Conservative Management (Mild to Moderate CTS)

1. Wrist Splinting:

   • Position: Neutral position (0°) or slight extension (0-5°) 2
   • Duration: Night-only splinting is as effective as continuous wear 1
   • Type: Rigid or soft orthoses (no significant difference in outcomes) 2

2. Corticosteroid Injections:

   • Local corticosteroid injections provide greater symptom improvement than splinting at 6 weeks 1
   • Similar outcomes at 6 months compared to splinting 1

3. Ineffective Treatments (avoid these):

   • NSAIDs and acetaminophen (not shown to be beneficial) 1
   • Pyridoxine and diuretics (no better than placebo) 3

Step 2: Surgical Management

• Indications for surgery:

  • Severe CTS with objective weakness or sensory deficits
  • Failed conservative treatment (symptoms not resolved within 2-7 weeks) 4
  • Evidence of median nerve denervation 4

• Surgical options:

  • Complete division of the flexor retinaculum (carpal tunnel release) 4
  • Endoscopic and open techniques are equally effective 1
  • Post-operative immobilization is not necessary 4

Special Considerations

• Pregnancy: Treat conservatively as spontaneous postpartum resolution is common 3
• Predictors of good response to conservative treatment:
  • Symptom duration less than 3 months
  • Absence of sensory impairment at presentation 5

Prognosis

• Only approximately 10% of patients have lasting response to conservative treatment alone 6
• Most patients with mild to moderate CTS who fail conservative treatment will ultimately require surgical intervention 5

Key Pitfalls to Avoid

• Delaying surgical referral in patients with thenar atrophy or objective weakness
• Using ineffective treatments like NSAIDs or pyridoxine
• Prolonged immobilization after carpal tunnel release surgery
• Overlooking underlying conditions that may contribute to CTS