What is the treatment for carpal tunnel syndrome?

Treatment for Carpal Tunnel Syndrome

Conservative management should be the first-line treatment for mild to moderate carpal tunnel syndrome, followed by surgical intervention if symptoms persist or are severe. 1, 2

Diagnostic Approach

• Diagnosis primarily based on clinical presentation:
  • Pain and paresthesias in the median nerve distribution
  • Provocative tests (Phalen's maneuver, Tinel's sign)
  • Thenar atrophy (late finding, highly specific) 2
• Electrodiagnostic studies only needed for:
  • Atypical presentations
  • Excluding other causes
  • Gauging severity for surgical prognosis 2

Treatment Algorithm

Step 1: Conservative Management (Mild to Moderate CTS)

1. Wrist Splinting

   • Neutral position wrist splint (0-5 degrees extension) 3
   • Night-only splinting is as effective as continuous wear 2
   • Should be worn for at least 3-9 weeks 4, 3
   • Most effective when symptom duration is less than 3 months 4

2. Corticosteroid Injections

   • Local corticosteroid injections provide greater symptom improvement than splinting at 6 weeks 2
   • Can be used in conjunction with splinting 4
   • May provide longer symptom relief than oral medications 5

3. Ultrasound Therapy

   • Can be considered as an adjunct therapy 5

Step 2: Surgical Management

• Indicated for:
  • Severe CTS with objective weakness or sensory deficits
  • Failed conservative management
  • Symptoms lasting more than 3 months with sensory changes 4, 2
• Surgical options:
  • Open carpal tunnel release
  • Endoscopic carpal tunnel release (both techniques equally effective) 2

Effectiveness of Treatments

• Only about 10% of patients have lasting response to conservative treatment alone 1, 4
• Predictors of successful conservative treatment:
  • Symptom duration less than 3 months
  • Absence of sensory impairment at presentation 4
• Surgical treatment is more effective than non-surgical options for long-term symptom relief 1

Special Considerations

• Pregnant women should be treated conservatively as spontaneous postpartum resolution is common 5
• Patients with thenar wasting or obvious underlying causes may need earlier surgical referral 4

Ineffective Treatments

• NSAIDs, acetaminophen, pyridoxine (vitamin B6), and diuretics have not shown benefit over placebo 5, 2

The evidence clearly shows that while conservative management should be attempted first in mild to moderate cases, surgical intervention provides more definitive long-term relief for most patients with carpal tunnel syndrome.