What are the treatment options for a patient with carpal tunnel syndrome?

Treatment of Carpal Tunnel Syndrome

Surgical decompression is the most effective treatment for carpal tunnel syndrome and should be offered to patients with severe disease (objective weakness, sensory deficits, or thenar atrophy) or those who fail 4-6 weeks of conservative management. 1, 2

Initial Conservative Management

For patients with mild to moderate carpal tunnel syndrome, begin with conservative treatment before considering surgery 1, 3:

First-Line Conservative Options

Wrist splinting in a neutral position is the primary conservative intervention:

• Night-only splinting is as effective as continuous wear 2
• A neutral wrist splint may be more effective than an extension splint 2
• Continue for 4-6 weeks before reassessing 1, 3

Local corticosteroid injection into the carpal tunnel:

• Provides slightly greater symptom improvement compared to splinting at 6 weeks 2
• Can provide relief for more than one month and delay surgery at one year 3
• Should be administered before considering surgery if conservative treatment is chosen 1
• Critical pitfall: Do not inject corticosteroids within 3 months of planned surgery, as this increases infection risk 1

Oral corticosteroids are an option for short-term management (2-4 weeks) 4, 5

Ineffective Treatments to Avoid

Discontinue these medications immediately, as they provide no benefit 1, 2:

• NSAIDs (ibuprofen, naproxen) 1, 2, 4
• Acetaminophen 1, 2
• Diuretics 4, 3
• Vitamin B6 (pyridoxine) 4, 3

Heat therapy should not be used 5

Surgical Indications

Proceed directly to surgical decompression in these scenarios 1, 2, 3:

• Severe carpal tunnel syndrome with objective weakness, sensory deficits, or thenar atrophy 2, 3
• Failed conservative treatment after 4-6 weeks 1, 3
• Patient preference for early surgery 5
• Clinical evidence of median nerve denervation on electrodiagnostic studies 5

Important caveat: Do not proceed directly to surgery in patients with very mild electrodiagnostic findings without attempting conservative treatment first, as 48-63% will respond to conservative measures 1

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 1, 3
• Complete division of the flexor retinaculum is required 5
• Routine epineurotomy is not recommended 5
• Do not immobilize the wrist postoperatively after routine surgery 5

Prognostic Factors for Surgical Success

Better outcomes occur with 1:

• Age younger than 40 years
• Symptom duration less than 1 year
• Less severe preoperative disease

Diagnostic Confirmation When Needed

While typical cases do not require additional testing, electrodiagnostic studies should be obtained 2, 3:

• In atypical presentations to confirm diagnosis
• Before planned surgery to determine severity and prognosis
• When considering other diagnoses (cervical radiculopathy, polyneuropathy)

Ultrasound can measure median nerve cross-sectional area and is highly sensitive and specific 1

Special Considerations

Laboratory testing is generally not recommended for typical carpal tunnel syndrome, but consider checking HbA1c, TSH, and vitamin B12 if systemic disease is suspected 1

Pregnant patients should be treated conservatively, as spontaneous postpartum resolution is common 4