Treatment of Carpal Tunnel Syndrome
The treatment of carpal tunnel syndrome should follow a stepwise approach, beginning with conservative measures for mild to moderate cases and progressing to surgical intervention for severe cases or those that fail conservative management. 1, 2
Diagnosis
Before initiating treatment, confirm the diagnosis through:
- Clinical presentation: Pain and paresthesias in the distribution of the median nerve (palmar aspect of thumb, index, middle fingers, and radial half of ring finger)
- Physical examination findings:
- Positive Phalen maneuver (wrist flexion test)
- Positive Tinel's sign
- Median nerve compression test
- Thenar atrophy (late finding, highly specific)
For atypical presentations, diagnostic confirmation may include:
- Electrodiagnostic studies (nerve conduction studies)
- Ultrasonography 3
Treatment Algorithm
1. Conservative Management (First-Line for Mild to Moderate CTS)
Wrist Splinting
- Neutral wrist position splinting is more effective than extension splinting 2
- Night-only splinting is as effective as continuous wear 2
- Should be worn consistently, especially at night 4
Corticosteroid Injections
- Local corticosteroid injections provide symptom relief for more than one month 1
- More effective than splinting at 6 weeks (similar outcomes at 6 months) 2
- Can delay the need for surgery at one year 1
- Should be performed with ultrasound guidance when possible 4
Activity Modification
- Relative rest and avoiding repetitive wrist movements 4
- Ergonomic education and workplace modifications 4
Physical Therapy
- Tendon gliding exercises
- Eccentric strengthening exercises 4
Other Conservative Options
- Therapeutic ultrasound
- Yoga 1
2. Surgical Management
Surgical decompression should be offered to patients with severe carpal tunnel syndrome or whose symptoms have not improved after 4-6 months of conservative therapy. 1
Indications for surgery:
- Severe CTS with objective weakness or sensory deficits 2
- Failed conservative treatment after 4-6 months 1
- Evidence of thenar muscle atrophy 4
- Severe symptoms or functional limitations 4
Surgical options:
- Endoscopic carpal tunnel release
- Open carpal tunnel release
Both techniques are equally effective, but patients return to work approximately one week earlier with endoscopic repair 1, 2
Ineffective Treatments
The following treatments have not shown benefit for carpal tunnel syndrome:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) 1, 5, 2
- Diuretics 1, 5
- Vitamin B6 (pyridoxine) 1, 5
- Over-the-counter analgesics 2
Special Considerations
Pregnant Women
- Treat conservatively as spontaneous postpartum resolution is common 5
Recalcitrant CTS
- May occur in up to 25% of patients after carpal tunnel release 6
- Most commonly due to incomplete transverse carpal ligament release or incorrect initial diagnosis 6
- Patients with recurrent symptoms often have perineural fibrosis 6
Monitoring and Follow-up
- Regular monitoring of symptoms and range of motion is crucial to prevent long-term complications 4
- Early detection and treatment are essential to prevent progression 4
- If symptoms worsen or do not improve with conservative management within 4-6 months, consider surgical referral 1
Prognosis
- Early intervention improves outcomes
- Surgical treatment relieves symptoms significantly better than non-surgical treatment for severe CTS 4
- Without proper treatment, CTS can lead to permanent nerve damage and muscle atrophy
Remember that treatment should be guided by symptom severity, with conservative approaches for mild to moderate cases and surgical intervention for severe cases or those that fail conservative management.