Management of Carpal Tunnel Syndrome
For patients with mild to moderate CTS, initiate conservative management with nighttime wrist splinting in neutral position as first-line therapy, reserving surgical decompression for severe cases with objective weakness/sensory deficits or after 4-6 months of failed conservative treatment. 1, 2
Initial Assessment and Diagnosis
Confirm the diagnosis clinically before initiating treatment, looking specifically for:
- Pain and paresthesias in the median nerve distribution (thumb, index, middle fingers, and radial half of ring finger) 3, 2
- Positive Phalen maneuver and median nerve compression test 3
- Thenar atrophy (late finding, highly specific) 2
Obtain electrodiagnostic studies when surgical management is being considered to determine severity and surgical prognosis 1. However, do not delay conservative treatment while awaiting these studies in typical presentations 3.
Treatment Algorithm by Severity
Mild to Moderate CTS (No Objective Weakness or Sensory Deficits)
Step 1: Nighttime Wrist Splinting
- Use neutral position splinting (not extension) as initial therapy 1, 2
- Night-only splinting is as effective as continuous wear 2
- Continue for 4-6 weeks before escalating treatment 1
Step 2: If Inadequate Response to Splinting
- Add local corticosteroid injection, which provides symptom improvement for longer than oral corticosteroids 1, 4, 5
- Injection is especially effective when symptoms are intermittent rather than constant and there is no thenar atrophy 4
- Critical pitfall to avoid: Do not inject corticosteroids within 3 months of planned surgery, as this increases infection risk 1
Step 3: Adjunctive Conservative Measures
- Nerve-gliding exercises and activity modification (avoiding sustained gripping and awkward wrist positions) 6
- Consider yoga as supplemental therapy 3
- Therapeutic ultrasound may provide benefit 3
Severe CTS (Objective Weakness, Sensory Deficits, or Thenar Atrophy)
Proceed directly to surgical decompression without prolonged conservative trials 1, 2. Surgical decompression is the most effective treatment for moderate to severe CTS, providing significantly better symptom relief than non-surgical options 1.
Surgical options:
- 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 1, 3
What NOT to Do
Discontinue ineffective medications:
- NSAIDs (acetaminophen, ibuprofen) have limited efficacy for nerve compression and do not address the underlying pathology 1, 2, 5
- Pyridoxine (vitamin B6) is no more effective than placebo 4, 5
- Diuretics are no more effective than placebo 4, 5
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.
Special Population: Pregnancy
Use conservative management exclusively in pregnant patients 7:
- Nighttime wrist splinting is the recommended initial management 7
- Surgery is absolutely contraindicated as initial management given the high rate of spontaneous postpartum resolution 7
- Avoid injections as first-line when conservative splinting has not been attempted due to theoretical risks during pregnancy 7
Prognostic Factors for Surgical Success
Better outcomes are associated with:
- Age younger than 40 years (significantly higher postoperative improvement scores, p < 0.001) 1
- Shorter symptom duration (<1 year before surgery) 1
- Less severe preoperative neurological status 1
Timeline for Treatment Decisions
Reassess at 4-6 weeks after initiating conservative treatment 1, 2. If symptoms have not improved to the patient's satisfaction or recur, refer for surgical evaluation 6. Do not continue ineffective conservative treatment beyond 4-6 months before offering surgical decompression 3, 2.