Treatment of Carpal Tunnel Syndrome
Surgical decompression (open or endoscopic carpal tunnel release) is the most effective treatment for carpal tunnel syndrome, providing superior symptom relief compared to all non-surgical options, and should be offered to patients with moderate-to-severe disease or those who fail 4-6 months of conservative management. 1, 2, 3, 4
Initial Treatment Approach
Conservative Management (First-Line for Mild-to-Moderate CTS)
Nighttime wrist splinting is the cornerstone of conservative therapy and should be attempted for at least 6 weeks before considering surgery. 2, 4, 5
- Splinting provides symptom relief in approximately 54% of patients at 3 months, though 41% will eventually require surgery within 18 months. 4
- This approach is particularly appropriate for patients with mild symptoms and minimal functional impairment. 6, 5
Local corticosteroid injection into the carpal tunnel provides relief for more than one month and can delay surgery at one year. 5
- Critical timing consideration: If injection is performed, wait a minimum of 3 months before proceeding to surgery to minimize infection risk. 2, 7
- Injecting within 3 months of planned surgery significantly increases infection rates without meaningful benefit. 2, 7
Ineffective Therapies to Avoid
Discontinue NSAIDs (ibuprofen) and acetaminophen as they have limited efficacy for nerve compression and do not address the underlying median nerve entrapment. 2, 8
- Diuretics and vitamin B6 are also not effective therapies. 5
Surgical Treatment (Definitive Management)
Indications for Surgery
Proceed directly to surgical consultation in the following scenarios:
- Severe CTS with progressive functional deficits (thenar atrophy, persistent numbness, weakness). 6, 5
- Moderate CTS with symptoms significantly impacting daily function. 2
- Failed conservative management after 4-6 months. 2, 5
- Patients with shorter symptom duration (<1 year) achieve better surgical outcomes. 2
Surgical Technique Selection
Both open and endoscopic carpal tunnel release are equally effective for symptom relief, with success rates of 80% at 3 months and 90% at 18 months. 2, 4
- Endoscopic repair allows patients to return to work approximately one week earlier than open technique. 2, 5
- The choice between techniques can be based on surgeon expertise and patient preference given equivalent outcomes. 2
Expected Surgical Outcomes
Success rates are excellent: 71% of surgically treated patients achieve treatment success at 3 months compared to 52% with splinting alone (relative risk 1.38,95% CI 1.08-1.75). 3, 4
- At 18 months, surgical success increases to 90% versus 75% for splinting. 4
- Younger patients (<40 years) show significantly higher postoperative improvements compared to older patients (p<0.001). 2
- Re-operation rates are very low (relative risk 0.04). 3
Common Pitfalls 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. 2
Do not rely on over-the-counter analgesics as adequate conservative treatment—they do not address median nerve compression. 2
Do not inject corticosteroids if surgery is planned within 3 months, as this increases infection risk. 2, 7
Obtain electrodiagnostic studies before surgery when clinical examination is positive and surgical management is being considered, to determine severity and surgical prognosis. 2