What are the treatment options for carpal tunnel syndrome?

Carpal Tunnel Syndrome Treatment

For mild to moderate carpal tunnel syndrome, begin with nighttime wrist splinting in neutral position and consider local corticosteroid injection if splinting fails within 4-6 weeks; for severe cases with objective weakness, sensory deficits, or thenar atrophy, proceed directly to surgical decompression. 1, 2

Initial Conservative Management (Mild to Moderate Cases)

First-Line Treatment: Splinting

• Nighttime wrist splinting in neutral position is the primary conservative treatment, worn for at least 4-6 weeks before considering other interventions 1, 2
• Night-only splinting is equally effective as continuous wear, making it more practical for patients 3
• Neutral wrist position splints may be more effective than extension splints 3
• 48-63% of patients with very mild electrodiagnostic findings will respond to conservative measures, making it essential to attempt this before surgery 1

Second-Line Treatment: Corticosteroid Injection

• Local corticosteroid injection into the carpal tunnel provides greater symptom improvement than splinting at 6 weeks, with similar outcomes at 6 months 3
• Injections can provide relief for more than one month and delay the need for surgery at one year 2
• Critical pitfall: Do not inject corticosteroids within 3 months of planned surgery, as this increases infection risk 1

Ineffective Treatments to Avoid

• Discontinue NSAIDs (ibuprofen) and acetaminophen, as they have limited efficacy for nerve compression and do not address the underlying pathology 1, 3
• Diuretics and vitamin B6 (pyridoxine) are ineffective for symptom relief 2, 4
• Heat therapy should not be used 5

Other Conservative Options with Limited Evidence

• Oral corticosteroids are an option, though evidence is conflicting 4, 5
• Therapeutic ultrasound may provide long-term relief (limited evidence) 2, 4
• Physical therapy and yoga are options 2

Surgical Indications

Proceed Directly to Surgery When:

• Severe carpal tunnel syndrome with objective weakness, sensory deficits, or thenar atrophy 3
• Clinical evidence of median nerve denervation on electrodiagnostic studies 5
• Patient preference for early surgery 5

Proceed to Surgery After Failed Conservative Treatment:

• Symptoms persist or worsen after 4-6 months of conservative therapy 2, 5
• Current nonsurgical treatment fails to resolve symptoms within 2-7 weeks 5

Surgical Approach

Technique Selection

• Both open carpal tunnel release and endoscopic carpal tunnel release are equally effective for symptom relief 1, 2
• Endoscopic repair allows patients to return to work approximately one week earlier than open technique 1, 2
• Complete division of the flexor retinaculum is the recommended surgical treatment 5
• Routine epineurotomy is not suggested 5

Perioperative Management

• Preoperative antibiotics are an option 5
• Do not immobilize the wrist postoperatively after routine carpal tunnel surgery 5

Prognostic Factors for Surgical Success

Favorable Indicators:

• Age younger than 40 years shows significantly higher postoperative improvement (p < 0.001) 1
• Symptom duration less than 1 year is associated with better surgical outcomes 1
• Shorter preoperative symptom duration predicts better results across all treatment modalities 1

Diagnostic Confirmation Before Surgery

• Obtain electrodiagnostic studies before surgical decompression to determine severity and surgical prognosis 2
• Ultrasound can measure median nerve cross-sectional area and is highly sensitive and specific compared to clinical assessment 1

Common Pitfalls to Avoid

• Never proceed directly to surgery in patients with very mild electrodiagnostic findings without attempting conservative treatment first 1
• Never rely on acetaminophen or NSAIDs as adequate conservative treatment 1
• Never inject corticosteroids within 3 months of planned surgery 1
• Avoid excessive immobilization postoperatively, as it can lead to muscle deconditioning 1