What are the treatment options for carpal tunnel syndrome?

Treatment Options for Carpal Tunnel Syndrome

Conservative management should be attempted first in mild to moderate carpal tunnel syndrome cases, while surgical treatment is more effective for long-term symptom relief. 1

Initial Conservative Management

Conservative treatment options include:

1. Wrist Splinting

   • Neutral position wrist splint worn at night 2, 3, 4
   • Night-only splinting is as effective as continuous wear 3
   • Neutral position splints may be more effective than extension splints 3

2. Corticosteroid Injections

   • Local corticosteroid injections provide greater symptom improvement compared to splinting at 6 weeks 3
   • Outcomes become similar at 6 months 3
   • May provide longer symptom relief than other conservative measures 5

3. Activity Modification

   • Avoid prolonged gripping activities 2
   • Avoid awkward wrist positions 2
   • Nerve-gliding exercises 2
   • Yoga may be beneficial as complementary therapy 2

4. Other Conservative Approaches

   • Pain-relieving modalities during activity 2
   • Ultrasound therapy 5

Important Note: Only about 10% of patients have lasting response to conservative treatment alone 6. Patients with symptom duration less than 3 months and absence of sensory impairment are more likely to have lasting response to conservative measures 6.

When to Consider Surgery

Surgical intervention should be considered when:

1. Conservative treatment fails to provide adequate relief 2, 3
2. Symptoms recur after initial improvement with conservative measures 2
3. Patient presents with severe CTS including:
   • Objective weakness 3
   • Sensory deficits 3
   • Thenar muscle atrophy (highly specific late finding) 3, 4

Surgical Options

• Both endoscopic and open carpal tunnel release techniques are equally effective 3, 4
• Surgery typically involves a small skin incision under microscope and local anesthesia 4
• Long-term outcomes regarding pain, numbness, function, and relapse rates do not significantly differ between open and endoscopic approaches 4

Treatment Algorithm

1. For mild to moderate CTS:

   • Start with neutral wrist splinting at night
   • Add activity modification and nerve-gliding exercises
   • If no improvement after 3-4 weeks, consider corticosteroid injection

2. For severe CTS or failed conservative management:

   • Refer for surgical evaluation
   • Surgical decompression (open or endoscopic carpal tunnel release)

Common Pitfalls to Avoid

• Ineffective treatments: NSAIDs, vitamin B6 (pyridoxine), and diuretics have not shown benefit beyond placebo 3, 5
• Delayed surgical referral: Patients with thenar atrophy or persistent symptoms despite conservative management should be promptly referred for surgical evaluation 2, 4
• Overreliance on conservative measures: Remember that only about 10% of patients have lasting response to conservative treatment alone 6

Special Considerations

• Pregnancy: CTS should be treated conservatively in pregnant women as spontaneous postpartum resolution is common 5
• Diagnostic uncertainty: Electrodiagnostic studies can confirm diagnosis in atypical cases, exclude other causes, and gauge severity for surgical prognosis 3