Treatment

Carpal tunnel syndrome may resolve spontaneously in around one third of patients over a 10-15 month period (1).

Non-surgical treatment are considered in mild to moderate disease, whereby pain and numbness are intermittent and there is no wasting or weakness of the thenar muscles & includes:

• avoidance/ minimising activities that exacerbate symptoms and patient reassurance
  • should apply to all patients- especially important for patients with elements of repetitive strain injury (RSI) or work-related upper limb disorder (WRULD). Some patients with WRULD have been shown to have reduced median nerve mobility on MRI scan ('tethering') but to be without CTS on nerve conduction testing
  • use of ergonomic equipment (e.g., wrist rest, mouse pad), taking breaks, use of keyboard alternatives (e.g., digital pen, voice recognition and dictation software), and alternating job functions may be useful
  • there is inconsistent evidence of effectiveness of work place modifications is lacking
• night-time splints
  • night splinting in a neutral position (0° of extension) has been shown to be helpful to a greater or lesser extent (1,2)
    • use of nocturnal wrist splints can give symptomatic relief and will allow carpal tunnel syndrome to settle in 30% of cases. Splinting will also help prevent further deterioration in patients awaiting surgical decompression (2)
  • is the recommended treatment option in primary care (benefits should be apparent within 8 weeks)
• local steroids
  • patients who remain symptomatic after more conservative measures may be considered for injection of the carpal tunnel with steroid (1)
    • a systematic review revealed that local corticosteroid injection relieved symptoms more than placebo and oral corticosteroids in the short term (3)
      • local corticosteroid (hydrocortisone) injections improve symptoms in 70-80% of patients but may require repeat injections. Failure of corticosteroid injections or power loss should prompt referral for surgical decompression of the carpal tunnel (4)

Surgical management should be considered in patients with severe or constant symptoms, progressive motor or sensory deficit, or if there is no improvement within 3 months of conservative treatment (1).

• surgical treatment is by complete division of the flexor retinaculum and decompression of the tunnel. The operation is successful in approximately 80% of patients.

Patients should be referred there is:

• diagnostic uncertainty
• failed conservative treatments
• severe symptoms or noticeable functional limitations
• relapse after successful carpal tunnel injections
• recurrence after carpal tunnel surgery
• request by patient (5)

Notes:

• there is study evidence that pregabalin is effective in ameliorating symptoms and improving functional outcomes in mild to moderate idiopathic CTS (6)

Reference:

• (1) Burton C, Chesterton LS, Davenport G. Diagnosing and managing carpal tunnel syndrome in primary care. Br J Gen Pract. 2014;64(622):262-3.
• (2) LeBlanc KE, Cestia W .Carpal tunnel syndrome. Am Fam Physician. 2011;83(8):952-8.
• (3) Marshall S et al. Local corticosteroid injection for carpal tunnel syndrome.Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001554.
• (4) Arthritis Research Campaign (June 2004). Hands On - Carpal Tunnel Syndrome.
• (5)Middleton SD, Anakwe RE Carpal tunnel syndrome. BMJ. 2014;349:g6437
• (6) Kumar B et al. Evaluating the Effect of Pregabalin in the Treatment of Carpal Tunnel Syndrome: A Prospective, Randomized, Triple-Blinded, Placebo-controlled Trial. The Clinical Journal of Pain 39(11):p 604-610, November 2023