eMedicine Specialties > Neurology > Electromyography and Nerve Conduction Studies
Median Neuropathy: Treatment & Medication
Updated: Mar 27, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Conservative treatment is usually recommended.
- Wrist splint: A lightweight plastic/Velcro splint in a neutral position that allows semifree finger movement is recommended. Precautions should be taken to prevent a persistently stiff wrist, sometimes called the "frozen wrist" syndrome, that is caused by prolonged immobilization.
- Modify activity: Reduce wrist flexion, extension, rotation, finger flexion, and forceful gripping.
- A local steroid injection may be considered. Local injection may have a distinctive role as a predictor of response to surgical release.
- Corticosteroids (usually DepoMedrol 40-80 mg) are injected adjacent to the carpal tunnel.
- Care must be taken not to inject the carpal tunnel, any tendon, or the nerve itself. Such an injection may increase the intracarpal tunnel pressure and cause additional nerve injury.
- The effect of steroid injections may be seen within a few days and often lasts for several weeks or months.
- The main disadvantage of this treatment is that the effect is often temporary.
- Unfortunately, repeated use (more than 2 or 3 injections) is not advised because of the possibility of local tendon damage.
- Local injection may not be advisable for CTS in the presence of systemic disease, mass lesions (at the wrist), or a major bony deformity. Early surgery may be needed in these cases.
- Complications include increased median nerve deficit, local infection, reflex sympathetic dystrophy, and tendon rupture.
Surgical Care
- Surgical decompression may be indicated in the following situations:
- Patient is older than 50 years.
- Symptoms persist (eg, >10 mo) despite conservative therapy.
- The distal median neuropathy is severe and associated with axonal loss, with reduced compound motor action potential.
- Evidence of thenar atrophy and persistent hypesthesia
- Low median motor and sensory amplitudes from axonal loss seen on nerve conduction studies
- Evidence of denervation in distal median innervated muscles on electromyography (EMG)
- Mass lesion is noted (eg, nerve tumor, ganglion cyst).
- Urgent surgery may be needed in acute CTS following local trauma, especially if the wrist and hand are swollen with sensory changes shortly after trauma.
- Open carpal tunnel release was compared with steroid injection in a study reported in 2005. According to the study, surgery resulted in better symptomatic and neurophysiologic outcome but not grip strength in patients with idiopathic carpal tunnel syndrome over a 20-week period.
- Surgical release may provide satisfactory relief in 75-90% of these cases.
- Causes of incomplete relief from surgery include incomplete section of flexor retinaculum, multifactorial hand symptoms, and an incorrect preoperative diagnosis.
- Recurrent postsurgical symptoms after initial success may be caused by perineural fibrosis, progressive tenosynovitis, or recurrent fibrosis of flexor retinaculum.
- New symptom patterns after surgery include joint stiffness, nerve branch injury, reflex sympathetic dystrophy, and infection.
- Endoscopic release: This procedure is currently investigational. It carries an increased risk of injury to the digital branches of the median nerve.
Consultations
If CTS surgery is required, an experienced neurosurgeon, plastic surgeon, or hand surgeon should be consulted.
Diet
No specific diet is indicated for patients with CTS. A low-salt diet may be indicated if fluid retention is a contributing factor.
Activity
Prolonged, repetitive use of the wrist (especially with force) may aggravate this condition.
- Provide an optimal work environment.
- Ergonomic changes in the workplace can be helpful.
- Work should be placed 10-12 inches in front of the eyes.
- Elbows should be postured at an angle of 85-100°.
- Shoulder should be in the vertical position, with abduction no greater than 20°.
- Wrist should be in the neutral position, without ulnar or radial deviation, with minimal flexion or extension.
- Environmental conditions such as temperature extremes and vibration should be minimized.
Medication
Nonsteroidal anti-inflammatory medications (NSAIDs) frequently are prescribed for this condition; caution patients to watch for the usual adverse effects. Short-term diuretic treatment may be helpful in patients with limb swelling. One study reported better symptomatic relief with short-term, low-dose steroid (20 mg qd x 2 wk, then 10 mg qd x 2 wk).
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents have analgesic and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions. Various NSAIDs may be used.
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderately severe pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Adult
500 mg PO bid
Pediatric
Not established
Probenecid may increase toxicity; anticoagulants may prolong PT (watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug; avoid use in third trimester
Ibuprofen (Ibuprin, Advil, Motrin)
DOC for mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
May decrease effects of loop diuretics; anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in congestive heart failure, hypertension, and decreased renal or hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Ketoprofen (Oruvail, Orudis, Actron)
For relief of mild to moderately severe pain and inflammation. Small dosages indicated initially in patients with small body size, the elderly, and those with renal or liver disease.
Doses >75 mg do not increase therapeutic effects.
Administer high doses with caution and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
May decrease effects of loop diuretics; anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in congestive heart failure, hypertension, and decreased renal or hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Flurbiprofen (Ansaid)
May inhibit cyclooxygenase, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
May decrease effects of loop diuretics; anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Corticosteroid agents
A recent report suggested that short-term oral steroids may be beneficial in CTS.
Prednisolone (AK-Pred, Delta-Cortef, Articulose-50, Econopred)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Adult
20 mg PO qd for 2 wk, followed by 10 mg qd for another 2 wk
Pediatric
Not established
Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects
Documented hypersensitivity; viral, fungal, or tubercular skin lesions
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis
More on Median Neuropathy |
| Overview: Median Neuropathy |
| Differential Diagnoses & Workup: Median Neuropathy |
 Treatment & Medication: Median Neuropathy |
| Follow-up: Median Neuropathy |
| References |
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References
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[Best Evidence] Hui AC, Wong S, Leung CH, et al. A randomized controlled trial of surgery vs steroid injection for carpal tunnelsyndrome. Neurology. Jun 28 2005;64(12):2074-8. [Medline].
Levine BP, Jones JA, Burton RI. Nerve entrapments of the upper extremity: A surgical perspective. Neurol Clin. Aug 1999;17(3):549-65, vii. [Medline].
Morgan G, Wilbourn AJ. Cervical radiculopathy and coexisting distal entrapment neuropathies: double-crush syndromes?. Neurology. Jan 1998;50(1):78-83. [Medline].
Nuber GW, Assenmacher J, Bowen MK. Neurovascular problems in the forearm, wrist, and hand. Clin Sports Med. Jul 1998;17(3):585-610. [Medline].
Preston DC, Shefner JM, Rutkove SB. Electrodiagnosis of carpal tunnel syndrome: too many and too few tests. American Academy of Neurology Annual Meeting. 1999;2PC003.
Preston DC. Distal median neuropathies. Neurol Clin. Aug 1999;17(3):407-24, v. [Medline].
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Further Reading
Keywords
carpal tunnel syndrome, upper extremity (UE) cumulativetrauma disorders, median neuropathy at the wrist, CTS, entrapment neuropathy, compression of the median nerve
