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, especially for moderate to severe cases, while nonsurgical options like splinting and corticosteroid injections are appropriate initial treatments for mild to moderate cases. 1

Diagnostic Approach

• 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 and has high sensitivity and specificity for diagnosis 1
• Provocative maneuvers such as the Phalen test and Tinel sign have varying sensitivity and specificity for diagnosis, while thenar atrophy is a late finding highly specific for CTS 2

Treatment Algorithm

Nonsurgical Options (First-Line for Mild to Moderate CTS)

1. Splinting:

   • Night-only splinting is as effective as continuous wear 2
   • Neutral wrist splint may be more effective than an extension splint 2
   • Should be considered as initial treatment for mild to moderate cases 3

2. Local Corticosteroid Injections:

   • Provide significant symptom improvement for up to 3-6 months 4
   • Probably reduce the need for surgery at one year 4
   • Offer slightly greater improvement of symptoms compared to splinting at 6 weeks, with similar outcomes at 6 months in recent-onset CTS 2
   • Adverse events are uncommon but may include temporary pain and localized swelling 4

3. Other Conservative Options:

   • Physical therapy, therapeutic ultrasound, and yoga may be beneficial 3
   • Over-the-counter analgesics such as NSAIDs and acetaminophen have not shown benefit for CTS 2
   • Diuretics and vitamin B6 are not effective therapies 3

Surgical Options (For Severe CTS or Failed Conservative Treatment)

• Indications for surgery:

  • Severe CTS with objective weakness or sensory deficits 2
  • Failure to improve after 4-6 months of conservative therapy 3
  • Acute CTS secondary to infection or trauma 5

• Surgical techniques:

  • Open carpal tunnel release and endoscopic techniques are equally effective for symptom relief 1, 3
  • Endoscopic repair allows patients to return to work approximately one week earlier than open repair 1, 3

Special Considerations

• Recalcitrant CTS:

  • May occur in up to 25% of patients who undergo carpal tunnel release 5
  • Most commonly results from incomplete transverse carpal ligament release or incorrect initial diagnosis 5
  • Patients with recurrent symptoms often have perineural fibrosis that tethers the median nerve 5

• Post-surgical evaluation:

  • Ultrasound examination should be the first-line imaging study to evaluate persistent symptoms after carpal tunnel release 1
  • Can identify potential causes such as incomplete decompression or development of post-surgical complications 1

Treatment Effectiveness

• Local corticosteroid injections provide moderate-certainty evidence of symptom improvement for up to 6 months and reduced need for surgery at one year 4
• Surgical decompression provides significantly better long-term symptom relief than non-surgical options 1, 3