Carpal Tunnel Syndrome Treatment
For mild to moderate carpal tunnel syndrome, initiate nighttime wrist splinting in neutral position combined with corticosteroid injection if symptoms persist beyond 4-6 weeks; for severe cases with objective weakness or sensory deficits, proceed directly to surgical decompression. 1, 2, 3
Initial Conservative Management (Mild to Moderate Cases)
First-Line Treatment
- Wrist splinting in neutral position for nighttime wear is the cornerstone of conservative therapy 1, 4, 3
- Night-only splinting is as effective as continuous wear, making it more practical for patients 3
- Neutral wrist position splints may be more effective than extension splints 3
- Continue splinting for 4-6 weeks before escalating treatment 1, 2
Corticosteroid Injection
- Local corticosteroid injection into the carpal tunnel provides superior short-term relief compared to splinting alone 1, 2, 3
- At 6 weeks, corticosteroid injections show slightly greater symptom improvement than splinting, though outcomes equalize by 6 months 3
- Injections can 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
Adjunctive Therapies
- Nerve-gliding exercises and activity modification (avoiding sustained gripping and awkward wrist positions) can complement splinting 4
- Physical therapy focusing on optimal postural alignment and normal movement patterns may provide benefit 1
- Therapeutic ultrasound and yoga have shown some efficacy 2
Treatments to Avoid
Discontinue ineffective over-the-counter analgesics including NSAIDs, acetaminophen, diuretics, and vitamin B6, as these have no proven efficacy for nerve compression 1, 2, 3, 5
Surgical Intervention
Indications for Surgery
- Severe carpal tunnel syndrome with objective weakness, thenar atrophy, or sensory deficits warrants immediate surgical referral 1, 2, 3
- Failure of conservative management after 4-6 months 1, 2
- Patient dissatisfaction with symptom relief despite adequate conservative trial 4
Surgical Technique
- Both open and endoscopic carpal tunnel release are equally effective for symptom relief 1, 2, 3
- Endoscopic repair allows patients to return to work approximately one week earlier than open technique 1, 2
- Surgical decompression provides the strongest evidence base and is the most effective treatment for moderate to severe cases 1
Prognostic Factors
- Patients younger than 40 years show significantly better postoperative outcomes (p < 0.001) 1
- Shorter symptom duration (<1 year) predicts better surgical results 1
- 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
Diagnostic Confirmation
While not required for typical presentations, electrodiagnostic studies should be obtained before surgery to determine severity and surgical prognosis 2, 3