Treatment of Pinched Nerve (Nerve Compression/Entrapment)
Initial Conservative Management (First-Line Treatment)
Conservative treatment should be implemented for at least 6 weeks before considering any surgical intervention, as most nerve compression injuries involve neurapraxia (mild ischemia from compression) that responds well to non-operative management. 1, 2
Immediate Conservative Measures
Rest and activity modification: Eliminate or reduce activities that provoke symptoms, as continued compression worsens neural dysfunction through both ischemic and mechanical factors 3, 1
Splinting/immobilization: Apply splints at the affected joint (wrist for carpal tunnel, elbow for ulnar/radial nerve) to maintain neutral positioning and reduce dynamic compression 1, 4
Physical therapy with neural gliding exercises: This addresses the connective tissue "container" tightness (epineurial and perineurial fibrosis) that interferes with blood flow and nerve excursion—often the primary pathology rather than nerve fiber damage itself 3
Anti-inflammatory medications: NSAIDs to reduce local inflammation and edema contributing to compression 1
Corticosteroid injections: Consider for localized compression sites when oral medications are insufficient 1
Pain Management for Neuropathic Symptoms
If neuropathic pain develops (burning, tingling, shooting pain), add pharmacologic treatment:
Pregabalin (Level A evidence): Established as effective and should be offered as first-line for neuropathic pain 5
Alternative agents (Level B evidence): Gabapentin, duloxetine, venlafaxine, or amitriptyline should be considered if pregabalin is not tolerated or contraindicated 5
Topical capsaicin 8% patch: For localized neuropathic pain, apply for 30-60 minutes under medical supervision with mandatory pretreatment using topical lidocaine 4% for 60 minutes; provides relief lasting up to 12 weeks 6
Low-concentration capsaicin cream (0.075%): Apply 3-4 times daily for 6 weeks for localized symptoms, though expect initial burning sensation 6
Diagnostic Confirmation Required Before Surgery
Electrodiagnostic testing (nerve conduction studies and needle electromyography) must corroborate the clinical diagnosis before any surgical treatment is considered. 1, 2
Clinical examination and history are often sufficient for diagnosis, but advanced testing (MRI, ultrasound, or electrodiagnostic studies) is indicated if conservative management fails after 6 weeks 2
EDx studies help differentiate demyelination (prolonged latency) from axonal injury, which guides prognosis and treatment decisions 3
Surgical Indications (After Failed Conservative Treatment)
Surgery should be considered only in specific circumstances after adequate conservative trial:
Timing for Surgical Exploration
Closed injuries with nerve in continuity: Follow clinically and electrically for 2-5 months; if no reversal of neurologic deficit occurs, proceed with surgical exploration 7
Sharp complete transection: Acute repair is indicated, especially if proximally located 7
Blunt division with bruised stumps: Tack stumps to adjacent planes and perform secondary repair at 2-4 weeks 7
Additional Surgical Indications
Refractory pain: Unresponsive to medical treatment, especially if the nerve requires repair due to persistent neurologic loss 7
Progressive neurologic deficit: Despite conservative management 1, 2
Anatomic abnormality causing compression: Identified on imaging that cannot be addressed conservatively 2
Common Pitfalls to Avoid
Premature surgery: Most compression neuropathies present with demyelination and symptoms related to connective tissue pathology rather than nerve fiber damage—these respond to conservative treatment 3
Inadequate conservative trial: Minimum 6 weeks required before surgical consideration 1
Missing multilevel compression: Neural tension tests and assessment of nerve gliding throughout the extremity are essential, as symptoms may relate to compression at multiple sites 3
Ignoring physical therapy: Neural gliding exercises specifically address the histopathologic fibrosis and restore nerve excursion—this is often more effective than surgery for symptom relief 3
Expected Outcomes
The vast majority of patients with compression neuropathy present with minimal electrophysiologic changes (prolonged latency) or even normal studies, indicating that symptoms primarily relate to connective tissue pathology rather than nerve fiber damage—this supports excellent prognosis with conservative management 3. Recovery from neurapraxia (the most common injury pattern seen in primary care) typically occurs with conservative treatment, while more severe injuries (axonotmesis or neurotmesis) may require surgical intervention 2.