Medical Care
Conservative treatment is usually recommended for mild-to-moderate carpal tunnel syndrome (CTS), at least initially. Guidelines from the American Academy of Orthopaedic Surgeons suggest that if symptoms fail to resolve within 2-7 weeks with a particular treatment, the clinician should move on to a different form of therapy. [44]
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Wrist splint: A lightweight plastic/Velcro splint in a neutral position that allows semifree finger movement is recommended. The wrist splint should be worn primarily at night (regularly) and as needed during daytime (during manual activity). Precautions should be taken to prevent a persistently stiff wrist caused by prolonged immobilization.
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Activity modification: Reduce wrist flexion, extension, rotation, finger flexion, and forceful gripping.
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A local steroid injection [45] may be particularly helpful in patients with mild CTS and intermittent symptoms. Local injection may also have a diagnostic or prognostic role as a predictor of response to surgical release. See a detailed description in the Medscape Reference article Carpal Tunnel Steroid Injection.
Corticosteroids (methylprednisolone acetate [DepoMedrol] 10-20 mg or triamcinolone acetonide [Kenolog] 10-20 mg) are injected adjacent (proximal) to the carpal tunnel, after local anesthesia.
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 effect is usually only temporary and usually wears off by 1 year. It may be particularly helpful in pregnant patients or those with temporary medical conditions such as hypothyroidism.
Repeated use beyond 2-3 injections is not recommended due to the greater risk of damage to the flexor tendons, including tendon rupture.
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Other complications include increased median nerve deficit, local infection, and reflex sympathetic dystrophy. A study comparing daily application of lidocaine 2.5% plus prilocaine 2.5% (EMLA) with a single injection of methylprednisolone acetate found that the anesthetic cream was effective and well tolerated. [46]
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Oral medications are listed in the Medication section below. A short course of nonsteroidal anti-inflammatory medication is often recommended, if there is no contraindication, without clear evidence of its effectiveness.
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Alternative therapies: These include acupuncture; yoga-based programs for stretching, strengthening, and relaxation; and chiropractic therapy.
Surgical Care
The decision to proceed to carpal tunnel release (CTR) surgery should be driven by the preference of the patient. [47] Surgery is indicated in most patients with moderate–to-severe CTS. [48]
According to a Cochrane review in 2008, surgical treatment of carpal tunnel syndrome relieved symptoms significantly better than splinting. A significant proportion of people treated medically eventually required surgery, and the risk of reoperation in surgically treated patients was low. Complications were more common in the surgical arm (RR 1.38, 95% CI, 1.08-1.76). [49]
In a 2005 comparison study of open carpal tunnel release with steroid injection, surgery resulted in better symptomatic and neurophysiologic outcome but not grip strength in patients with idiopathic CTS over 20 weeks. [50]
In a 2009 randomized multicenter study of patients with CTS without denervation, surgical treatment led to modestly better outcome than multimodality, nonsurgical treatment (including hand therapy and ultrasonography). [51]
The American Academy of Orthopaedic Surgeons provides treatment guidelines, including surgical recommendations. Regardless of the specific technique used, surgical treatment of carpal tunnel syndrome should involve complete division of the flexor retinaculum. [44]
Indications for surgical decompression
See the list below:
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Acute CTS due to local trauma (fracture, hematoma, infection) (requires surgical decompression as soon as possible) [52]
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Mass lesion (eg, nerve tumor, ganglion cyst)
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Severe CTS on clinical examination
Significant weakness or atrophy of the thenar muscles
Persistent numbness and paresthesias in the median sensory territory
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Severe electrodiagnostic abnormalities with documented axonal loss
Decreased compound motor action potential on NCS
Denervation in distal median innervated muscles on electromyography
Surgery techniques
Surgery includes complete resection of the transcarpal ligament by open or endoscopic techniques.
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Classic open CTR surgery requires a longitudinal incision from the distal wrist crease to the palm, about 5-6 cm in length. Modifications with limited open release surgeries have been described.
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Endoscopic surgery is done by either single or dual portal techniques, with overall similar success rate than open surgery. [53]
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According to a Cochrane review in 2004, no strong evidence supports open or endoscopic surgery for CTR, and the decision seems to be guided by surgeon and patient preferences. [54]
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The overall success rate with endoscopic CTR surgery is reported as 96.5%, with a complication rate of 2.7% and a failure rate of 2.6%. [55]
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The endoscopic technique has a slightly higher risk of injury to the median nerve. In some reports, patients with endoscopic surgery experience less pain and have earlier return to work and daily activities. [55]
Complications
See the list below:
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Transient paresthesias of the ulnar and median nerves are common.
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Tenderness of the surgical scar is greater after open surgery and may persist for up to 1 year.
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Superficial palmar arch injuries, reflex sympathetic dystrophy, and flexor tendon lacerations can occur.
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Causes of incomplete relief from surgery include incomplete section of flexor retinaculum, multifactorial hand symptoms, and an incorrect preoperative diagnosis.
Consultations
If CTS surgery is required, an experienced neurosurgeon, plastic surgeon, or hand surgeon should be consulted.
Diet
See the list below:
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No specific diet is indicated for patients with CTS. A low-salt diet may be indicated if fluid retention is a contributing factor.
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The effectiveness of vitamin B-6 supplementation is questionable, but many patients use it on their own as adjunct therapy. Although doses of less than 200 mg daily are unlikely to cause adverse effects, patients should be monitored for vitamin B-6 toxicity, particularly when high doses are taken over long periods. [56]
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One European study has reported reduction in symptoms and functional impairment with alpha-lipoic acid, 600 mg, and gamma-linolenic acid, 360 mg, daily for 90 days in 112 patients with moderately severe carpal tunnel syndrome. [57]
Activity
Prolonged, repetitive use of the wrist (especially with force) may aggravate this condition.
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Provide an optimal work environment.
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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.
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Scars from carpal tunnel release surgery.
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Anatomy of the carpal tunnel.
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Anatomy of the median nerve and the carpal tunnel.
