What are the symptoms and treatment options for carpal tunnel syndrome?

Symptoms and Treatment Options for Carpal Tunnel Syndrome

Carpal tunnel syndrome is characterized primarily by numbness and tingling in the thumb, index, middle, and radial half of the ring finger, with weakness of thumb opposition in severe cases. 1

Symptoms

Sensory Symptoms

• Numbness and tingling in the distribution of the median nerve (thumb, index, middle finger, and radial half of the ring finger) 1, 2
• Pain, often worse at night, that may radiate to the forearm 2, 3
• Paresthesias that may be relieved by "flicking" the hand 2
• Decreased sensitivity in fingertips in advanced cases 3

Motor Symptoms

• Weakness of thumb opposition in severe cases 1
• Decreased grip strength 3
• Muscle wasting of the thenar eminence in advanced cases 3
• Loss of dexterity for fine motor tasks 3

Associated Findings

• Symptoms often worsen at night or with repetitive hand activities 2
• Bilateral carpal tunnel syndrome may be an early sign of certain systemic conditions or amyloidosis 4
• May be associated with other conditions like obesity, diabetes, pregnancy, and certain occupations 1, 3

Diagnostic Evaluation

Physical Examination Tests

• Durkan maneuver (applying firm digital pressure across the carpal tunnel) - 64% sensitive, 83% specific 1
• Phalen maneuver (wrist flexion for 60 seconds) 2
• Tinel sign (tapping over the median nerve) 2
• Median nerve compression test 2

Diagnostic Studies

• Ultrasound is highly sensitive and specific for diagnosis of carpal tunnel syndrome 4
• Electrodiagnostic studies (nerve conduction studies and electromyography) are the gold standard with >80% sensitivity and 95% specificity 1, 5
• MRI can diagnose carpal tunnel syndrome with high accuracy but is typically not indicated for routine evaluation 4

Treatment Options

Conservative Management

• Wrist splinting is the first-line treatment for mild to moderate carpal tunnel syndrome 2, 6

  • Night-time splinting may result in higher rates of overall improvement compared to no treatment 6
  • Should be worn in a neutral position 2
  • May provide benefits in the long term rather than short term 6

• Local corticosteroid injection 2, 3

  • Can provide relief for more than one month 2
  • May delay the need for surgery at one year 2
  • Particularly effective when combined with immobilization 1

• Activity modification 2

  • Decreasing repetitive activities 3
  • Using ergonomic devices 3
  • Avoiding activities that exacerbate symptoms 2

Treatments Not Supported by Evidence

• Nonsteroidal anti-inflammatory drugs (NSAIDs) 2, 3
• Diuretics 2, 3
• Vitamin B6 (pyridoxine) 2, 3

Surgical Management

• Indicated for patients with:

  • Severe carpal tunnel syndrome 2
  • Symptoms that have not improved after 4-6 months of conservative therapy 2
  • Progressive neurological deficits 3

• Surgical approaches:

  • Open carpal tunnel release 2, 5
  • Endoscopic carpal tunnel release 2, 5
  • Both techniques are equally effective for long-term outcomes 2, 3
  • Patients return to work approximately one week earlier with endoscopic repair 2

Special Considerations

• Occupational factors may contribute to carpal tunnel syndrome, particularly work involving high pressure, high force, repetitive movements, and vibrating tools 5
• Obesity and diabetes are significant risk factors 1, 3
• Women are more commonly affected than men 1, 5
• Median age of onset is typically middle age 5

Treatment Algorithm

1. For mild symptoms:

   • Begin with night-time wrist splinting for 6-12 weeks 6
   • Consider activity modifications 2

2. For moderate symptoms or if splinting fails:

   • Local corticosteroid injection 2
   • Continue splinting 2

3. For severe symptoms or failed conservative management:

   • Refer for surgical evaluation 2
   • Either open or endoscopic surgical decompression 2, 5