Treatment of Carpal Tunnel Syndrome
For mild to moderate carpal tunnel syndrome, begin with nighttime wrist splinting in neutral position and consider local corticosteroid injection, reserving surgical decompression for severe cases or those failing 4-6 months of conservative therapy. 1, 2
Initial Conservative Management
Conservative treatment should be attempted first for mild to moderate cases:
- Nighttime wrist splinting in neutral position is the cornerstone of initial therapy and should be implemented immediately 1, 2, 3
- Local corticosteroid injection provides symptom relief for more than one month and can delay surgery for at least one year 2, 3
- Physical therapy, therapeutic ultrasound, and yoga are additional conservative options 2
Discontinue ineffective medications:
- Stop acetaminophen and ibuprofen, as NSAIDs have limited efficacy for nerve compression and do not address the underlying median nerve compression 1, 4
- Avoid diuretics and vitamin B6, which are no more effective than placebo 2, 4
Timing of Surgical Intervention
Proceed directly to surgical decompression in these scenarios:
- Severe carpal tunnel syndrome with clinical evidence of median nerve denervation 1, 3
- Failure of conservative therapy after 4-6 months 1, 2, 3
- Patient preference for early surgery when denervation is present 3
Critical pitfall to avoid: 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
Surgical Technique
Both open and endoscopic carpal tunnel release are equally effective:
- Complete division of the flexor retinaculum is the definitive surgical treatment 3
- Endoscopic repair allows patients to return to work approximately one week earlier than open technique 1, 2
- Both approaches provide equivalent symptom relief 1, 2
Surgical considerations:
- Obtain electrodiagnostic studies before surgery to determine severity and surgical prognosis 2
- Preoperative antibiotics are an option 3
- Do not routinely immobilize the wrist postoperatively after routine carpal tunnel surgery 3
- Avoid corticosteroid injection within 3 months of planned surgery, as this increases infection risk 1
Prognostic Factors for Surgical Success
Better outcomes are associated with:
- Shorter symptom duration (<1 year) before surgery 1
- Younger age (<40 years) shows significantly higher postoperative improvement compared to older patients 1
- Less severe preoperative neurological status 1
Special Considerations
Acute carpal tunnel syndrome (related to fractures, hemorrhage, or vascular disorders) requires urgent surgical intervention to avoid serious sequelae, unlike the chronic idiopathic form 5
Pregnancy-related carpal tunnel syndrome should be treated conservatively, as spontaneous postpartum resolution is common 4