What is the management of carpal tunnel syndrome?

Management of Carpal Tunnel Syndrome

The most effective treatment for carpal tunnel syndrome is surgical decompression, which provides significantly better symptom relief than non-surgical options, especially for moderate to severe cases. 1

Diagnosis

• Carpal tunnel syndrome is primarily diagnosed through clinical evaluation combined with electrophysiologic studies 1
• Ultrasound can be used to measure median nerve size in patients with clinical symptoms 1
• Classic symptoms include pain and paresthesias in the distribution of the median nerve (palmar aspect of thumb, index and middle fingers, and radial half of ring finger) 2
• Physical examination findings such as the flick sign, Phalen maneuver, and median nerve compression test can help confirm the diagnosis 2
• Thenar atrophy is a late finding and highly specific for carpal tunnel syndrome 3

Treatment Algorithm

Step 1: Conservative Management for Mild to Moderate Cases

• Wrist splinting:

  • Splint the wrist in neutral position for nocturnal wear 4
  • Night-only splinting is as effective as continuous wear 3
  • A neutral wrist splint may be more effective than an extension splint 3

• Corticosteroid injections:

  • Local corticosteroid injections can provide relief for more than one month and delay the need for surgery at one year 2
  • In patients with recent onset of CTS, corticosteroid injections provide slightly greater improvement of symptoms compared with splinting at 6 weeks 3
  • Patients with symptom duration of less than 3 months and absence of sensory impairment may have better response to conservative treatment 5

• Additional conservative approaches:

  • Nerve-gliding exercises and activity modification, including avoidance of protracted periods of sustained gripping activities and awkward wrist positions 4
  • Therapeutic ultrasound and yoga may provide some benefit 2

• Ineffective treatments to avoid:

  • Nonsteroidal anti-inflammatory drugs, diuretics, and vitamin B6 are not effective therapies 2, 3

Step 2: Surgical Management

• Indications for surgery:

  • Severe carpal tunnel syndrome (including objective weakness or sensory deficits) 3
  • Symptoms that have not improved after four to six months of conservative therapy 2
  • Presence of thenar atrophy 3

• Surgical options:

  • Both open carpal tunnel release and endoscopic carpal tunnel release are equally effective for symptom relief 1, 2
  • Endoscopic repair allows patients to return to work approximately one week earlier than open release 1, 2

Special Considerations

• Pregnant women with carpal tunnel syndrome should be treated conservatively as spontaneous postpartum resolution is common 6
• Electrodiagnostic studies should be obtained before surgery to determine severity and surgical prognosis 2
• Conservative treatment is only effective long-term in approximately 10% of patients 5
• Patients with mild symptoms and short duration (less than 3 months) are more likely to respond to conservative treatment 5

Treatment Efficacy

• Surgical decompression provides the most reliable and long-lasting symptom relief 1, 2
• Conservative treatments typically offer only temporary relief in the majority of patients 5
• The combination of steroid injections and wrist splinting has a long-term effect in only about 10% of patients 5