What are the treatment options for carpal tunnel syndrome?

Treatment Options for Carpal Tunnel Syndrome

Surgical decompression is the most effective treatment for carpal tunnel syndrome, providing significantly better symptom relief than non-surgical options, especially for moderate to severe cases. 1, 2

Diagnosis and Assessment

• Carpal tunnel syndrome (CTS) presents with pain and paresthesias in the distribution of the median nerve (palmar aspect of thumb, index, middle fingers, and radial half of ring finger) 3, 4
• Physical examination findings include:
  • Positive Phalen maneuver and Tinel sign (varying sensitivity and specificity) 3
  • Thenar atrophy (late finding, highly specific for CTS) 3
• Electrodiagnostic studies are useful to:
  • Confirm diagnosis in atypical cases
  • Exclude other causes
  • Gauge severity for surgical prognosis 3, 4
• Ultrasound may be used to measure median nerve size in patients with clinical symptoms 1

Treatment Algorithm

Non-surgical Options (First-line for Mild to Moderate CTS)

1. Wrist Splinting:

   • Night-only splinting is as effective as continuous wear 3
   • Neutral wrist position is more effective than extension splinting 3
   • Provides symptom relief but less effective than surgery (54% success rate at 3 months vs. 80% for surgery) 2

2. Local Corticosteroid Injections:

   • Provides greater symptom improvement than splinting at 6 weeks 3
   • Can delay need for surgery for up to one year 4
   • Recommended before considering surgery 5

3. Other Conservative Options:

   • Ultrasound therapy may be beneficial 5, 6
   • Oral steroids can be effective for short-term management (2-4 weeks) 5, 6

Ineffective Treatments

• Over-the-counter analgesics including NSAIDs have not shown benefit 3, 6
• Diuretics and vitamin B6 are no more effective than placebo 6
• Heat therapy is not recommended 5

Surgical Options (For Severe CTS or Failed Conservative Treatment)

1. Surgical Indications:

   • Severe CTS with objective weakness or sensory deficits 3
   • Symptoms not improved after 4-6 months of conservative therapy 4
   • Evidence of median nerve denervation 5
   • Failed response to non-surgical treatment within 2-7 weeks 5

2. Surgical Techniques:

   • Open carpal tunnel release 1, 2
   • Endoscopic carpal tunnel release 1
   • Both techniques are equally effective for symptom relief 3, 4
   • Endoscopic repair allows patients to return to work approximately one week earlier 4
   • Complete division of the flexor retinaculum is recommended 5

Comparative Effectiveness

• Surgery provides superior outcomes compared to splinting:
  • 80% success rate at 3 months (vs. 54% for splinting) 2
  • 90% success rate at 18 months (vs. 75% for splinting) 2
  • Note that by 18 months, 41% of patients initially treated with splinting eventually required surgery 2

Special Considerations

• Pregnant women should be treated conservatively as spontaneous postpartum resolution is common 6
• Wrist immobilization is not necessary after routine carpal tunnel surgery 5
• Routine use of skin nerve preservation and epineurotomy is not recommended during carpal tunnel release 5

Monitoring Treatment Response

• Standardized assessment tools like the Boston Carpal Tunnel Questionnaire or Disabilities of the Arm, Shoulder, and Hand questionnaire can be used to evaluate treatment outcomes 5