Treatment of Carpal Tunnel Syndrome
For mild to moderate carpal tunnel syndrome, start with conservative treatment using neutral wrist splinting (especially at night) or local corticosteroid injections, but proceed directly to surgical decompression for severe cases with objective weakness, sensory deficits, or evidence of median nerve denervation. 1, 2
Initial Treatment Selection Algorithm
Severe Disease → Immediate Surgery
- Offer surgical decompression immediately if any of the following are present: 1, 2, 3
- Objective weakness (particularly thumb abduction)
- Sensory deficits on examination
- Thenar atrophy
- Electrodiagnostic evidence of median nerve denervation
Mild to Moderate Disease → Conservative Treatment First
Splinting as First-Line:
- Use a neutral wrist position splint rather than extension splints, as neutral positioning is more effective at reducing carpal tunnel pressure 2, 4
- Night-only splinting is equally effective as continuous wear, making it more practical for patients 2
- Continue for 4-6 weeks before reassessing 5, 3
Local Corticosteroid Injection:
- Provides symptom relief for more than one month and can delay surgery at one year 5
- In recent-onset carpal tunnel syndrome, injections show slightly greater improvement than splinting at 6 weeks, with similar outcomes at 6 months 2
- Consider this option before proceeding to surgery 3
Oral Corticosteroids:
- May be used for short-term management (2-4 weeks) but are less effective than local injections for sustained relief 6, 3
Treatments to Avoid
The following have NOT shown benefit and should not be used: 5, 2, 6
- NSAIDs (nonsteroidal anti-inflammatory drugs)
- Acetaminophen
- Diuretics
- Vitamin B6 (pyridoxine)
- Heat therapy 3
When to Proceed to Surgery
Surgical decompression is indicated when: 1, 5, 3
- Conservative treatment fails after 4-6 weeks
- Symptoms are severe at presentation (as defined above)
- Patient elects for early surgery after appropriate counseling 3
Surgical Technique Selection
- Both open and endoscopic carpal tunnel release are equally effective for symptom relief 1, 5, 2
- Endoscopic repair allows patients to return to work approximately one week earlier than open technique 1, 5, 2
- Complete division of the flexor retinaculum is the recommended surgical approach 3
Post-Operative Management
Key principles to optimize recovery: 1, 3
- Do not immobilize the wrist routinely after surgery—this can lead to muscle deconditioning and worse outcomes 1, 3
- Avoid excessive splinting post-operatively, as it prevents restoration of normal movement 1
- Encourage gradual increase in activity and functional use of the affected limb 1
- Consider physical therapy focusing on optimal postural alignment and normal movement patterns if symptoms persist 1
Important Pitfalls
Common mistakes to avoid:
- Prolonged immobilization after surgery worsens outcomes 1
- Using NSAIDs or vitamin B6 wastes time and resources without benefit 5, 2, 6
- Delaying surgery in severe cases with objective findings risks permanent nerve damage 2, 3
- In pregnant patients, treat conservatively as spontaneous postpartum resolution is common 6
Persistent Symptoms After Surgery
If numbness and pain persist post-operatively: 1
- Obtain ultrasound evaluation of the median nerve as first-line imaging to assess for incomplete decompression or complications 1
- Consider complex regional pain syndrome or coexisting polyneuropathy that may have been masked 1
- Trial conservative management with physical therapy for 4-6 weeks before considering surgical re-exploration 1