What are the recommended treatments for carpal tunnel syndrome?

Carpal Tunnel Syndrome: Presentation and Treatment

Surgical treatment is more effective than non-surgical options for long-term relief of carpal tunnel syndrome symptoms, though conservative management should be attempted first in mild to moderate cases. 1

Clinical Presentation

• Classic symptoms:

  • Pain and paresthesias in the median nerve distribution
  • Numbness/tingling in thumb, index, middle, and half of ring finger
  • Symptoms often worse at night or with repetitive hand activities
  • Weakness in thumb abduction (late finding)

• Physical examination findings:

  • Provocative maneuvers: Phalen test and Tinel sign (variable sensitivity/specificity)
  • Thenar atrophy (highly specific but late finding)
  • Hypalgesia and weak thumb abduction (more predictive of abnormal nerve conduction)

Diagnostic Approach

• Diagnosis primarily clinical for typical presentations
• Electrodiagnostic studies indicated for:
  • Atypical presentations
  • Excluding other causes
  • Determining severity for surgical prognosis
  • Note: Normal nerve conduction does not exclude CTS

Treatment Algorithm

1. Mild to Moderate CTS (without muscle wasting or severe sensory deficits)

First-line conservative treatments:

• Wrist splinting:

  • Neutral position wrist splint (more effective than extension splint) 2
  • Night-only splinting as effective as continuous wear 2
  • Continue for at least 6 weeks

• Corticosteroid injection:

  • Single injection of 20 mg methylprednisolone acetate into the carpal tunnel
  • Provides better symptom improvement than splinting at 6 weeks 3
  • Similar outcomes to splinting at 6 months 3

Second-line options:

• Ultrasound therapy 4
• Neural gliding exercises 5
• Manual therapy techniques 5

Ineffective treatments (not recommended):

• NSAIDs, pyridoxine (vitamin B6), and diuretics (no better than placebo) 4

2. Severe CTS (with muscle wasting, persistent symptoms, or severe sensory deficits)

• Surgical decompression:
  • Endoscopic or open carpal tunnel release (equally effective) 2
  • Indicated when:
    • Conservative measures fail
    • Symptoms persist beyond 6 months
    • Objective weakness or sensory deficits present
    • Electrodiagnostic studies show severe entrapment

Prognostic Factors

• Only approximately 10% of patients have lasting response to conservative treatment alone 6
• Factors predicting better response to conservative treatment:
  • Symptom duration less than 3 months
  • Absence of sensory impairment at presentation 6
  • Mild symptoms

Special Considerations

• Pregnancy: Treat conservatively as spontaneous postpartum resolution is common 4
• Underlying medical conditions: Address any contributing conditions (diabetes, hypothyroidism, rheumatoid arthritis)

Treatment Effectiveness

• Corticosteroid injections provide better short-term relief than splinting at 6 weeks 3
• Surgical intervention provides more definitive long-term relief than conservative measures 2
• Conservative treatments typically offer only temporary relief in most patients, with approximately 90% eventually requiring surgical intervention 6