What are the treatment options for carpal tunnel syndrome?

Treatment of Carpal Tunnel Syndrome

The treatment of carpal tunnel syndrome should begin with conservative measures such as splinting and corticosteroid injections, progressing to surgical decompression for severe cases or those failing conservative management after 4-6 months. 1

Diagnosis Confirmation

• Clinical evaluation combined with electrodiagnostic studies is recommended for diagnosis
• Electrodiagnostic studies are first-line confirmatory tests for:
  • Atypical presentations
  • Determining severity before surgery
• Imaging may be appropriate in selected cases:
  • Ultrasound to visualize median nerve compression
  • MRI without contrast in specific circumstances (not routine)

Conservative Treatment Options

First-Line Approaches

1. Wrist Splinting

   • Neutral-position wrist splint worn consistently, especially at night
   • Should be used for at least 6 weeks
   • Avoid continuous daytime splinting unless specifically indicated (can lead to muscle deconditioning)

2. Corticosteroid Injections

   • Effective for symptom relief in many cases
   • Should be performed with ultrasound guidance when possible
   • May provide only short-term relief in most patients
   • Patients with symptom duration less than 3 months and absence of sensory impairment respond better to conservative treatment 2

3. Activity Modification

   • Relative rest
   • Avoiding repetitive thumb and wrist movements
   • Ergonomic modifications

4. Physical/Occupational Therapy

   • Eccentric strengthening exercises
   • Tendon gliding exercises
   • Ergonomic education

5. Pain Management

   • NSAIDs for short-term pain relief (typically 1-2 weeks)
   • Topical NSAIDs may have fewer systemic side effects
   • Cryotherapy (ice application for 10-minute periods through a wet towel)
   • Opioids should be used only when other analgesics are not effective, with duration kept as short as possible

Less Effective Conservative Options

Evidence suggests the following are less effective or have conflicting evidence:

• Diuretics
• Pyridoxine (vitamin B6)
• Yoga
• Laser-acupuncture
• Ultrasound (conflicting evidence)
• Oral steroids (conflicting evidence) 3

Surgical Intervention

Indications for Surgery

• Symptoms persisting beyond 4-6 months of conservative therapy
• Evidence of thenar muscle atrophy
• Severe symptoms or functional limitations
• Failed conservative treatment

Surgical Approaches

• Both endoscopic and open carpal tunnel release techniques are equally effective
• Surgical treatment relieves symptoms significantly better than non-surgical treatment for severe CTS 1
• After 18 months, surgery has a success rate of 90% compared to 75% for splinting alone 4

Treatment Algorithm

1. Mild to Moderate CTS (no muscle wasting):

   • Start with wrist splinting at night for 6 weeks
   • Consider corticosteroid injection into the carpal tunnel
   • Implement activity modifications and ergonomic changes
   • If no improvement after 6 weeks, consider a second corticosteroid injection

2. Moderate to Severe CTS or Failed Conservative Treatment:

   • Refer for surgical evaluation if:
     • Symptoms persist beyond 4-6 months of conservative therapy
     • Evidence of thenar muscle atrophy develops
     • Severe symptoms or functional limitations continue

3. Post-Treatment Monitoring:

   • Regular assessment of symptoms and range of motion
   • Monitor for complications or symptom recurrence

Common Pitfalls and Caveats

• Conservative treatments offer long-term relief in only about 10% of patients 2
• Delaying surgery in appropriate candidates may lead to permanent nerve damage
• Continuous splinting during the day can lead to muscle deconditioning
• Patients with CTS symptoms for less than 3 months are more likely to respond to conservative treatment
• Patients with sensory changes are less likely to have lasting response to conservative treatment 2
• Occupational CTS is uncommon; exclude intrinsic factors such as obesity before attributing to occupation 5