What are the treatment options for carpal tunnel syndrome?

Carpal Tunnel Syndrome Treatment Options

Surgical treatment relieves symptoms significantly better than non-surgical treatment for carpal tunnel syndrome, though conservative management should be the first-line approach for mild to moderate cases. 1

Conservative Management Options (First-Line for Mild to Moderate CTS)

Wrist Splinting

• Night splinting with a rigid immobilization brace positioning the wrist in neutral to slight extension 1
• Should be worn primarily at night and during aggravating activities
• Night-only splinting is as effective as continuous wear 2
• A neutral wrist splint may be more effective than an extension splint 2

Activity Modification

• Rest and activity modification to prevent ongoing damage 1
• Avoidance of protracted periods of sustained gripping activities and awkward wrist positions 3
• Nerve-gliding exercises may be beneficial 3

Medications and Injections

• Local corticosteroid injections can resolve symptoms in approximately 61% of cases after a single injection 1
• In patients with recent onset of CTS, corticosteroid injections provide slightly greater improvement compared to splinting at 6 weeks 2
• NSAIDs (oral or topical) can be used for pain relief, though evidence for their effectiveness is limited 1, 4
• Ice therapy for 10-minute periods through a wet towel can provide symptom relief 1

Other Conservative Approaches

• Ultrasound therapy may be beneficial 3, 5
• Yoga and other exercises may complement the conservative program 3

Surgical Management (For Severe CTS or Failed Conservative Treatment)

Indications for Surgery

• Severe CTS with objective weakness or sensory deficits 2
• Thenar muscle atrophy 5
• Failed conservative treatment (symptoms not resolved within 2-7 weeks) 6

Surgical Techniques

• Both endoscopic and open carpal tunnel release techniques are equally effective 1, 2
• Complete division of the flexor retinaculum is the recommended surgical approach 1, 6
• Surgery can be performed under local anesthesia with a small skin incision under a microscope 5
• Routine use of skin nerve preservation and epineurotomy is not suggested 6

Post-Surgical Care

• Wrist immobilization is not recommended postoperatively after routine carpal tunnel surgery 6
• Regular monitoring of symptoms and range of motion is crucial 1

Treatment Algorithm

1. For Mild to Moderate CTS:

   • Begin with night splinting in neutral position
   • Implement activity modification and nerve-gliding exercises
   • Consider local corticosteroid injection if symptoms persist
   • Add ultrasound therapy or other complementary approaches as needed

2. For Severe CTS or Failed Conservative Treatment:

   • Surgical decompression (open or endoscopic carpal tunnel release)
   • Complete division of the flexor retinaculum
   • No postoperative immobilization
   • Regular follow-up to monitor recovery

Important Considerations

• Surgical treatment is associated with more complications than conservative management, highlighting the need for careful patient selection 1
• Pregnant women with CTS should be treated conservatively as spontaneous postpartum resolution is common 4
• Early detection and intervention are crucial to prevent long-term complications 1
• If symptoms are not relieved with conservative measures or they recur, referral to a hand surgeon for possible surgical decompression is recommended 3

Diagnostic Evaluation

• Ultrasound has high specificity (80-94%) and is more accessible and less expensive than MRI for diagnosis 1
• MRI without contrast has high sensitivity (95%) and specificity (95%) for diagnosing carpal tunnel syndrome 1
• Electrodiagnostic studies can confirm the diagnosis in atypical cases, exclude other causes, and gauge severity for surgical prognosis 2