What is the recommended treatment for carpal tunnel syndrome?

Treatment of Carpal Tunnel Syndrome

Surgical decompression is the most effective treatment for carpal tunnel syndrome, but should only proceed after failed conservative management in mild to moderate cases, while patients with severe disease (objective weakness, sensory deficits, or thenar atrophy) should be offered surgery directly. 1, 2

Initial Treatment Algorithm

Mild to Moderate CTS

Start with conservative management for 4-6 months before considering surgery 1, 3:

• Nighttime wrist splinting in neutral position is the cornerstone of conservative treatment and should be offered first-line 1, 3, 2

  • Night-only splinting is as effective as continuous wear 2
  • Neutral wrist position splints may be more effective than extension splints 2

• Local corticosteroid injection provides symptom relief for more than one month and can delay surgery at one year 1, 3

  • In recent-onset CTS, corticosteroid injections provide slightly greater symptom improvement compared with splinting at 6 weeks, with similar outcomes at 6 months 2
  • Critical pitfall: Do not inject corticosteroids within 3 months of planned surgery, as this increases infection risk 1

• Additional conservative options that may complement splinting include 3, 4:

  • Nerve-gliding exercises 4
  • Activity modification to avoid sustained gripping and awkward wrist positions 4
  • Therapeutic ultrasound 3
  • Yoga 3

Severe CTS

Proceed directly to surgical decompression without attempting conservative treatment in patients with 1, 2:

• Objective weakness
• Sensory deficits
• Thenar muscle atrophy 2, 5

Critical pitfall: Do not proceed directly to surgery in patients with very mild electrodiagnostic findings without attempting conservative treatment, as 48-63% will respond to conservative measures 1

Ineffective Treatments to Avoid

Discontinue the following medications, as they are not effective for nerve compression 1, 3, 2, 6:

• NSAIDs (acetaminophen, ibuprofen) 1, 2
• Diuretics 3, 6
• Vitamin B6 (pyridoxine) 3, 6

Surgical Options

When surgery is indicated after failed conservative management (4-6 months) or for severe disease 1, 3:

• Both open carpal tunnel release and endoscopic carpal tunnel release are equally effective for symptom relief 1, 3, 2, 5
• Endoscopic repair allows patients to return to work approximately one week earlier than open surgery 1, 3
• Long-term outcomes regarding pain, numbness, function, symptom relapse, and re-surgery rates do not differ significantly between techniques 5

Diagnostic Confirmation Before Surgery

If surgical decompression is planned, obtain electrodiagnostic studies to determine severity and surgical prognosis 3. However, recognize that an abnormal nerve conduction study is useful for ruling in CTS, but a normal test does not necessarily exclude it 2.

Special Considerations

• In pregnant women, treat conservatively as spontaneous postpartum resolution is common 6
• Consider laboratory testing (HbA1c, TSH, Vitamin B12) only if there are signs suggestive of systemic diseases causing reversible neuropathy 1
• Do not routinely perform laboratory testing in patients with typical CTS, as it generates more false positives than true positives 1