What are the treatment options for carpal tunnel syndrome?

Treatment Options for Carpal Tunnel Syndrome

For carpal tunnel syndrome, surgical decompression is more effective than non-surgical treatments for symptom relief, though conservative management should be the first-line approach for mild to moderate cases. 1

Initial Conservative Management

Conservative treatment options should be tried first for mild to moderate carpal tunnel syndrome:

1. Splinting

   • Use rigid immobilization brace rather than removable splints 2
   • Position wrist in neutral to slight extension 2
   • Night-only splinting is as effective as continuous wear 3
   • A neutral wrist splint may be more effective than an extension splint 3

2. Corticosteroid Injections

   • Local corticosteroid injections can resolve symptoms in approximately 61% of cases after a single injection 2
   • Provide slightly greater improvement compared to splinting at 6 weeks (with similar outcomes at 6 months) 3

3. Activity Modification and Rest

   • Modify activities to prevent ongoing nerve compression 2
   • Ice therapy for 10-minute periods through a wet towel 2

4. Medications

   • NSAIDs (oral or topical) may be used for pain relief 2
   • Note: Evidence suggests over-the-counter analgesics like NSAIDs and acetaminophen have not shown significant benefit specifically for CTS 3
   • Oral steroids are an option but typically provide only short-term relief (2-4 weeks) 4

5. Other Conservative Approaches

   • Ultrasound therapy may be considered 4
   • Specific manual techniques and neural gliding exercises have shown some benefit 5

When to Consider Surgery

Surgical intervention should be considered in the following circumstances:

• When objective weakness or sensory deficits are present 3
• When conservative treatments fail after 3-6 months 2
• In cases of severe carpal tunnel syndrome 3
• When nerve conduction studies show severe entrapment 4

Surgical Options

• Both endoscopic and open carpal tunnel release techniques are equally effective 1, 3
• Complete division of the flexor retinaculum is the recommended surgical approach 6
• Post-operative wrist immobilization is not necessary after routine carpal tunnel surgery 6

Treatment Algorithm

1. For mild to moderate CTS:

   • Start with night splinting in neutral position
   • If no improvement after 2-7 weeks, consider corticosteroid injection 6
   • Continue conservative management for up to 3-6 months if showing improvement

2. For severe CTS or failed conservative treatment:

   • Surgical decompression (either open or endoscopic technique)
   • Meta-analyses show surgical treatment relieves symptoms significantly better than non-surgical treatment 1

Monitoring and Follow-up

• Regular monitoring of symptoms and range of motion is crucial 2
• Use validated assessment tools like the Boston Carpal Tunnel Questionnaire to track progress 6

Important Caveats

• Surgical treatment, while more effective, is associated with more complications than conservative management 1
• Pregnant women should be treated conservatively as spontaneous postpartum resolution is common 4
• No single conservative treatment has been definitively proven superior to others, and combinations of treatments have shown varying results 5
• Early surgery is an option when there is clinical evidence of median nerve denervation 6