What are the treatment options for carpal tunnel syndrome?

Treatment Options for Carpal Tunnel Syndrome

For carpal tunnel syndrome, surgical treatment relieves symptoms significantly better than non-surgical treatment, particularly for patients with severe symptoms or those who have failed conservative management. 1

Initial Conservative Management

Conservative treatment is appropriate as first-line therapy for mild to moderate carpal tunnel syndrome:

• Splinting:

  • Night-only splinting is as effective as continuous wear 2
  • Neutral wrist position splinting is more effective than extension splinting 2
  • Should be worn consistently, especially at night 3
  • Avoid continuous daytime splinting unless specifically indicated, as this can lead to muscle deconditioning 3

• Anti-inflammatory measures:

  • Local corticosteroid injections provide better symptom improvement than splinting at 6 weeks (with similar outcomes at 6 months) 2
  • Corticosteroid injections resolve symptoms in approximately 61% of cases after a single injection 3
  • Note: Over-the-counter NSAIDs and acetaminophen have not shown benefit specifically for carpal tunnel syndrome 2

• Physical therapy:

  • Can include eccentric strengthening exercises, tendon gliding exercises, and ergonomic education 3
  • Combined with night splinting for mild to moderate cases 3

Treatment Algorithm

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

   • Begin with neutral wrist splinting at night for 6 weeks
   • Consider corticosteroid injection if symptoms persist
   • Re-evaluate after 8 weeks of conservative treatment 3

2. Moderate CTS with persistent symptoms:

   • If symptoms persist after 8 weeks of conservative treatment, consider corticosteroid injection (if not already tried)
   • Continue splinting
   • Consider surgical evaluation if symptoms persist beyond 4-6 months 3

3. Severe CTS (objective weakness, thenar atrophy, or severe sensory deficits):

   • Offer surgical decompression directly 2

Surgical Management

Surgical intervention is indicated when:

• Conservative treatment fails after 4-6 months 3
• Evidence of thenar muscle atrophy develops 3
• Severe symptoms or functional limitations are present 2

Surgical options:

• Both endoscopic and open carpal tunnel release techniques are equally effective 2, 4
• Complete division of the flexor retinaculum is recommended 4
• Routine use of skin nerve preservation and epineurotomy is not suggested 4
• Postoperative wrist immobilization is not necessary after routine carpal tunnel surgery 4

Effectiveness of Treatments

• Surgical treatment has higher success rates than splinting alone:

  • 80% success rate for surgery vs. 54% for splinting at 3 months
  • 90% success rate for surgery vs. 75% for splinting at 18 months (though 41% of splinting group patients eventually had surgery) 5

• For mild to moderate cases, a multimodal conservative approach may be sufficient, with approximately 75% of patients experiencing improvement with splinting alone by 18 months 5

Special Considerations

• Pregnancy: Carpal tunnel syndrome should be treated conservatively in pregnant women as spontaneous postpartum resolution is common 6

• Diagnostic confirmation: While clinical diagnosis is often sufficient, electrodiagnostic studies can confirm the diagnosis in atypical cases, exclude other causes, and gauge severity for surgical prognosis 2

• Monitoring: Regular assessment of symptoms and function is essential, with referral for surgical evaluation if conservative treatment fails 3

Common Pitfalls to Avoid

• Relying solely on NSAIDs for symptom relief, as they have not shown benefit over placebo 2, 6
• Continuous splinting during the day, which can lead to muscle deconditioning 3
• Delaying surgical referral for patients with thenar atrophy or severe symptoms 2
• Failing to recognize that a normal nerve conduction study does not necessarily exclude carpal tunnel syndrome 2