What are the treatment options for Carpal Tunnel Syndrome (CTS)?

Treatment Options for Carpal Tunnel Syndrome (CTS)

Conservative management should be the first-line approach for mild to moderate carpal tunnel syndrome, with surgical intervention reserved for severe cases or when conservative measures fail after 4-6 months. 1, 2

Initial Conservative Management

Splinting

• Night splinting with a neutral wrist position is as effective as continuous wear and should be the initial approach 1, 2
• Neutral wrist splints are more effective than extension splints 2
• Avoid continuous daytime splinting unless specifically indicated, as this can lead to muscle deconditioning 1

Anti-inflammatory Measures

• Local corticosteroid injections provide greater symptom improvement than splinting at 6 weeks (with similar outcomes at 6 months) 2
  • Particularly effective for acute symptom relief 1
• NSAIDs and acetaminophen have not shown significant benefit specifically for CTS 2
• Cryotherapy (ice application for 10-minute periods through a wet towel) can help manage pain and inflammation 1

Physical/Occupational Therapy

• Includes eccentric strengthening exercises, tendon gliding exercises, and ergonomic education 1
• Activity modification to avoid repetitive wrist movements 1

Treatment Escalation Algorithm

1. Mild to Moderate CTS (no muscle atrophy or severe sensory deficits)

   • Start with night splinting in neutral position for 2-7 weeks 1, 3
   • If inadequate response, add local corticosteroid injection 3
   • Consider ultrasound therapy as an option 3
   • Re-evaluate after 8 weeks of conservative treatment 1

2. Moderate to Severe CTS or Failed Conservative Treatment

   • Consider surgical referral if:
     • Symptoms persist beyond 4-6 months of conservative therapy 1
     • Evidence of thenar muscle atrophy develops 1, 2
     • Severe symptoms or functional limitations continue 1

Surgical Management

• Complete division of the flexor retinaculum (carpal tunnel release) is the recommended surgical approach 3
• Both endoscopic and open carpal tunnel release techniques are equally effective 1, 2
• Surgical treatment provides better symptom relief than non-surgical treatment for severe CTS 1, 3
• Routine use of skin nerve preservation and epineurotomy is not recommended 3
• Post-operative wrist immobilization is not necessary after routine carpal tunnel surgery 3

Monitoring and Follow-up

• Regular monitoring of symptoms and range of motion is crucial 1
• If symptoms persist after initial conservative treatment (2-7 weeks), consider alternative non-surgical treatment or surgery 3
• Use validated assessment tools like the Boston Carpal Tunnel Questionnaire or the Disabilities of the Arm, Shoulder, and Hand questionnaire to evaluate treatment response 3

Common Pitfalls to Avoid

• Delaying surgical referral when thenar atrophy is present (indicates advanced disease) 2
• Continuous splinting during the day, which can lead to muscle deconditioning 1
• Overlooking potential underlying conditions (diabetes, cervical radiculopathy) that may affect treatment response 3
• Relying solely on over-the-counter NSAIDs, which have not shown significant benefit for CTS 2

By following this evidence-based approach to CTS treatment, clinicians can effectively manage symptoms, preserve function, and minimize long-term complications for patients with this common condition.