What are the next steps for a 71-year-old patient with bilateral hand numbness and a feeling of swelling, especially when resting, and a history of carpal tunnel syndrome (CTS) who has not responded to gabapentin (neurontin)?

Management of Bilateral Carpal Tunnel Syndrome Unresponsive to Gabapentin

Discontinue gabapentin and proceed directly to corticosteroid injection or surgical decompression, as gabapentin has no proven efficacy for carpal tunnel syndrome and likely provides no clinically meaningful benefit. 1

Why Gabapentin is Ineffective for CTS

The most recent high-quality evidence definitively shows gabapentin does not work for carpal tunnel syndrome:

• A 2025 systematic review and meta-analysis found gabapentin provides no clinically important symptom relief compared to placebo, with only a 0.08-point improvement on the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) Symptom Severity Scale—far below the 1.14-point minimal clinically important difference. 1

• Gabapentin probably causes more fatigue (67% increased risk) and may cause more dizziness (96% increased risk) compared to placebo, making it harmful without benefit. 1

• This aligns with general neuropathic pain guidelines showing gabapentin has limited efficacy even in conditions where it's indicated, and older patients are particularly susceptible to adverse effects like dizziness, somnolence, and peripheral edema. 2

Immediate Next Steps

First-Line Treatment: Corticosteroid Injection

Local corticosteroid injection into or proximal to the carpal tunnel should be offered as the next intervention:

• Corticosteroid injection provides relief for more than one month and can delay the need for surgery at one year. 3

• In controlled trials, 77% of patients improved at 1 month after methylprednisolone 40 mg injection (compared to 20% with lidocaine alone), with a number needed to treat of 1.8. 4

• The injection can be administered just proximal to the carpal tunnel (4 cm proximal to the wrist crease, between the radial flexor and long palmar muscle tendons) at a 10-20 degree angle. 4

• This approach is particularly appropriate for patients with mild to moderate CTS who have failed conservative measures. 3

Confirm Diagnosis and Severity

Before proceeding, ensure the diagnosis is accurate and assess severity:

• If the presentation is atypical (bilateral symptoms at rest with "swelling" sensation is somewhat unusual), consider electrodiagnostic studies or ultrasonography to confirm CTS and rule out other causes like cervical radiculopathy, polyneuropathy, or thoracic outlet syndrome. 3

• If surgical decompression is being considered, electrodiagnostic studies should be obtained to determine severity and surgical prognosis. 3

• Look for positive physical examination findings: flick sign (shaking hands to relieve symptoms), positive Phalen maneuver, positive median nerve compression test, and positive Tinel's sign. 3, 5

Consider Alternative Medications (Limited Evidence)

If you must try another medication before injection or surgery:

• Pregabalin is NOT recommended despite its theoretical advantages over gabapentin, as it also showed no benefit in preventing or treating neuropathic pain in controlled trials and shares similar adverse effects. 6, 7, 8

• Duloxetine has stronger evidence than gabapentin for some neuropathic pain conditions (particularly chemotherapy-induced peripheral neuropathy), but there is no specific evidence supporting its use in CTS. 2

• NSAIDs, diuretics, and vitamin B6 are not effective therapies for CTS. 3, 9

Surgical Decompression

Patients with severe CTS or whose symptoms have not improved after 4-6 months of conservative therapy should be offered surgical decompression:

• Surgery is superior to conservative therapies for most persistently symptomatic patients. 3, 9

• Endoscopic and open techniques are equally effective, but patients return to work an average of one week earlier with endoscopic repair. 3

• At 71 years old, this patient is a reasonable surgical candidate if symptoms are significantly impacting quality of life and function. 3

Common Pitfalls

• Continuing ineffective gabapentin: The evidence is clear that gabapentin does not work for CTS, yet off-label use is increasing. 1

• Delaying definitive treatment: After 4-6 months of failed conservative therapy, continuing to try different medications delays effective treatment and risks permanent nerve damage. 3

• Not considering post-surgical residual symptoms: If this patient has already had surgery (the history is unclear), gabapentin may provide some benefit for residual nocturnal symptoms and sleep quality, though evidence is limited to small retrospective studies. 5

• Overlooking bilateral presentation: Bilateral CTS at rest with swelling sensation warrants consideration of systemic causes (diabetes, hypothyroidism, rheumatoid arthritis, pregnancy, acromegaly) or alternative diagnoses. 3