Version May 2024
INTRODUCTION — Carpal tunnel syndrome (CTS) refers to the complex of symptoms and signs brought on by compression of the median nerve as it travels through the carpal tunnel in the wrist. Patients commonly experience pain, paresthesia, and, less commonly, weakness in the median nerve distribution. CTS is the most common compressive focal mononeuropathy seen in clinical practice.
This topic will review the treatment of CTS. Other aspects of CTS are discussed separately.
●(See "Carpal tunnel syndrome: Pathophysiology and risk factors".)
●(See "Carpal tunnel syndrome: Clinical manifestations and diagnosis".)
ASSESS THE SEVERITY OF SYMPTOMS AND NERVE INJURY — Our approach to the management of patients clinically diagnosed with CTS is based on the severity of symptoms (algorithm 1).
Key characteristic symptoms of CTS include hand paresthesias and/or aching that worsens with sleep or sustained hand positions. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on 'Clinical diagnosis'.)
CTS symptoms can be categorized as mild, moderate, or severe (table 1):
●Mild CTS symptoms – Sensory impairment may include tingling or discomfort in the median nerve distribution (figure 1) but no persistent numbness or weakness. Symptoms do not disrupt sleep, impair hand function, or interfere with activities of daily living (ADLs).
●Moderate CTS symptoms – Persistent numbness is present in the median distribution (figure 1) or mild nocturnal symptoms occasionally disrupt sleep. Symptoms (sensory loss or pain) may interfere slightly with hand function, but the patient is able to perform all ADLs.
●Severe CTS symptoms – Weakness is present in the median distribution or symptoms are disabling, routinely disrupt sleep, or prevent the patient from carrying out one or more ADLs.
Initial nonsurgical treatment is appropriate for patients with a clinical diagnosis of CTS who have mild symptoms. (See 'Initial nonsurgical treatment for most patients' below.)
For patients with moderate or severe CTS symptoms, electrodiagnostic testing is performed when surgical intervention is considered to confirm the clinical diagnosis and to define the extent of median nerve injury. The severity of clinical symptoms may not always correlate with the severity of the injury to the median nerve (algorithm 1). (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on 'Diagnostic testing for patients with moderate to severe or atypical symptoms'.)
Electrodiagnostic criteria can be used to discriminate among mild, moderate, or severe CTS (table 1) [1].
●Mild CTS is characterized by prolonged (relative or absolute) sensory latencies; motor studies are normal. There is no evidence for axon loss.
●Moderate CTS is characterized by prolonged sensory and motor latencies. There is no evidence of axon loss.
●Severe CTS is characterized by evidence of axon loss, as defined by any of the following:
•An absent or low-amplitude sensory nerve action potential (SNAP) or mixed nerve action potential
•A low-amplitude or absent thenar compound muscle action potential (CMAP)
•Needle electromyography (EMG) with fibrillation potentials or motor unit potential changes (large amplitude, long-duration motor unit potentials, or excessive polyphasics)
Referral for surgical intervention is indicated for patients with electrodiagnostic evidence of severe median nerve injury (denervation or axon loss). (See 'Surgery for patients with severe or persisting symptoms' below.)
A trial of nonsurgical therapy may be offered to other patients with CTS that is mild or moderate by electrodiagnostic criteria, even in the presence of severe clinical symptoms. (See 'Initial nonsurgical treatment for most patients' below.)
INITIAL NONSURGICAL TREATMENT FOR MOST PATIENTS — For patients with a clinical diagnosis of CTS with mild symptoms, we suggest initial nonsurgical therapy. We also treat other patients with moderate to severe symptoms and electrodiagnostic features consistent with mild or moderate CTS (without axon loss) with initial nonsurgical measures.
Nonsurgical interventions include splinting, glucocorticoids, physical and occupational therapy techniques (eg, carpal bone mobilization and nerve-gliding exercises), yoga, and therapeutic ultrasound. Up to two-thirds of patients with mild to moderate CTS symptoms have successful outcomes with nonsurgical therapy [2,3].
Patients with moderate to severe CTS and axonal loss on electrodiagnostic testing and those whose symptoms persist or worsen despite initial nonsurgical therapy are typically referred for surgical decompression. (See 'Surgery for patients with severe or persisting symptoms' below.)
General measures for all patients — Several patient-level factors may contribute to the etiology of CTS including heredity, size of the carpal tunnel, associated local and systemic diseases, and habits. Predisposing conditions include thyroid disease, diabetes, obesity, rheumatoid arthritis, and other connective tissue diseases. (See "Carpal tunnel syndrome: Pathophysiology and risk factors", section on 'Risk factors'.)
Evaluation and management of these predisposing environmental factors and medical conditions is warranted, although it is uncertain whether treating these conditions will improve the symptoms or the course of CTS.
Initial therapy — We suggest nocturnal wrist splinting in the neutral position or a glucocorticoid injection as initial nonsurgical therapy. Splinting may be selected by patients who prefer a noninvasive approach. Glucocorticoid injection may be preferred by those who prioritize faster onset of symptom relief or who are unable to adhere to a regimen of wrist splinting. Either approach can reduce CTS symptoms and may delay or eliminate the need for surgery in mildly symptomatic patients [4,5].
Wrist splinting — A wrist splint or brace maintains the wrist in a neutral position, thus preventing prolonged flexion or extension of the wrist. Splinting may limit activities that raise pressure within the carpal tunnel or reduce its cross-sectional area.
●Regimen – Splints are usually worn at night, but they can be worn continuously. Night splinting alone can reduce symptom severity and improve median nerve conduction velocities [6-8]. Full-time splinting has been reported to improve median nerve conduction in small studies, but it may not improve symptoms when compared with night-only splinting [6,9].
Splints can be purchased over the counter (OTC) or be custom made by an occupational therapist with subspecialty certification in hand therapy. There are no studies comparing treatment outcomes with custom splints versus OTC models.
●Duration – A trial of one to two months is reasonable to assess the initial response to nocturnal splinting. Splinting may be continued longer or used continuously, if feasible, for patients who report improving symptoms. For those who report inadequate relief after an initial trial, additional therapies may be combined with splinting. (See 'Combination therapy' below.)
A 2023 systematic review found eight trials with 523 hands that evaluated nocturnal wrist splinting versus no treatment [10]. Splinting modestly improved short-term symptoms (<3 months), but available evidence was of low certainty and longer-term benefit was uncertain. Clinical features that may favor a long-term clinical response to splinting are shorter duration of symptoms (one year or less) and less severe nocturnal paresthesias [11].
Splinting and glucocorticoid injection appear similarly effective [10]. This was demonstrated in an open-label trial of 234 patients with mild to moderate CTS of at least six weeks in duration who were randomly assigned to a single methylprednisolone acetate injection (20 mg) or night splinting [12]. Patients in the glucocorticoid group had lower scores on the Boston Carpal Tunnel Questionnaire (BCTQ) at six weeks compared with the splinting group (adjusted mean difference -0.32 points, 95% CI -0.48 to -0.16), but the clinical significance of this small difference is unclear. In addition, all outcomes were similar at six months, including pain scores, insomnia, functional measures, and the proportion of patients referred to surgery (19 and 12 percent for injection and splinting groups, respectively). Adverse effects were mild and transient. Approximately half of patients reported increased hand or wrist pain immediately after injection, one-third of whom reported that pain lasted for more than three days before subsiding. Six percent of patients in the splinting group could not wear the splints as instructed due to discomfort.
In a follow-up study at 24 months that assessed the durability of initial treatment regimens, patients assigned to initial glucocorticoid injection or splinting had similar overall response rates, BCTQ scores, and pain scale scores [13]. Subsequent referral for surgery was more frequent in patients assigned initially to a glucocorticoid injection (28 versus 20 percent), but the generalizability of this finding is limited by the variable use of repeat injections or prolonged splinting as well as crossover treatments following the initial six-week trial and by the >30 percent loss to follow-up by 24 months.
Glucocorticoid injection — Injection of glucocorticoids into the region of the carpal tunnel is intended to reduce tissue inflammation and to aid recovery. For patients who are amenable to a minimally invasive option, injection is an alternative to splinting for short-term relief of symptoms.
●Regimen – We typically use a single injection of methylprednisolone (20 to 40 mg) with 1% lidocaine. Other glucocorticoids such as betamethasone may also be used. The carpal tunnel may be identified by ultrasound guidance or anatomic landmarks [14]. For injections proximal to the carpal tunnel, the wrist is extended and needle is typically inserted on the ulnar side of the palmaris longus tendon approximately 1 cm proximal to the wrist crease [15]. The needle is repositioned before injection if aspirated blood indicates vascular penetration or if immediate paresthesias indicate nerve penetration.
Glucocorticoids can also be injected distal to the carpal tunnel. In one study of 131 CTS patients receiving either proximal or distal injections, distal injections were found more painful, but there was no difference between groups in functional or symptomatic outcome at three months [16].
Referral to an occupational therapist with subspecialty certification in hand therapy may improve outcomes.
●Adverse effects – Injections appear to be generally a safe procedure. However, injection therapy is associated with several risks, including exacerbation of median nerve compression, accidental injection into the median or ulnar nerves, and digital flexor tendon rupture [17,18].
●Repeat injections – Although there is no clear consensus, we suggest limiting the frequency of glucocorticoid injections for symptom recurrence to no more than once every six months per wrist. For patients who report partial relief after an initial injection, additional therapies may be combined with a repeat injection. (See 'Combination therapy' below.)
For other patients with symptoms unresponsive to glucocorticoid injection and for those whose symptoms recur after one to two injections, we suggest other nonsurgical treatments or surgical evaluation. (See 'Additional nonsurgical options if initial therapy is ineffective' below and 'Surgery for patients with severe or persisting symptoms' below.)
Glucocorticoid injections are effective for short-term (one to three months) relief of CTS symptoms compared with placebo [19,20]. A 2023 systematic review that included 14 trials found that glucocorticoid injections provided greater improvement in both symptoms and hand function at three months than placebo [20]. In one trial, 81 patients with CTS refractory to splinting were assigned to injection with glucocorticoid (betamethasone 6 mg in 1 mL and 1 mL of 1% lidocaine) or sham (saline plus lidocaine) [21]. Patients treated with glucocorticoids were likelier to report significant symptom relief at two weeks following the injection than those treated with sham injections (70 versus 34 percent, respectively). When nonresponders to sham injection subsequently received a betamethasone injection, the proportion reporting subsequent symptom improvement was 73 percent. In another trial, 111 patients with CTS were assigned to treatment with injections of methylprednisolone 80 mg, methylprednisolone 40 mg, or placebo in a 1:1:1 ratio [19]. Most patients were symptomatic for >1 year and had symptoms unresponsive to splinting. At 10 weeks, improvement in CTS symptom severity score was significantly greater for the methylprednisolone 80 mg and methylprednisolone 40 mg groups compared with placebo.
Glucocorticoid injections also provide longer term symptomatic benefit and may reduce the need for surgery, but these data are less certain [20]. In an uncontrolled extension of a trial using betamethasone that reported benefit in 70 percent, only 4 of 46 patients (9 percent) whose CTS symptoms improved following an initial injection had good symptomatic control for up to 18 months [21]. Additional injections (two to seven) controlled symptoms in 13 others (28 percent); surgical referral was requested by 18 patients (43 percent). Similarly, in the trial assessing methylprednisolone versus placebo at 10 weeks, the benefits of methylprednisolone were lost by assessment at one year [19]. In a follow-up analysis of this study at five years, symptom severity remained similar between groups and most had undergone carpal tunnel release surgery (91 percent) [5]. However, treatment with methylprednisolone 80 mg and 40 mg was associated with a delay in the need for surgery compared with placebo (mean 180 and 185 versus 121 days). The generalizability of these results is somewhat limited by the inclusion of patients with prolonged symptoms (>1 year). Additional data are warranted to assess the long-term effect of glucocorticoid injections for patients with recent-onset or milder symptoms.
The effectiveness of glucocorticoid injection appears similar to wrist splinting. (See 'Wrist splinting' above.)
Additional nonsurgical options if initial therapy is ineffective — For patients with partial or transient improvement with either splinting or glucocorticoid injection as initial nonsurgical therapy, we suggest combination therapy with both measures. For patients with persistent symptoms that are partially responsive to splinting and glucocorticoids, we add other nonsurgical options.
For patients whose symptoms persist or worsen despite nonsurgical therapy, we refer for surgical intervention. (See 'Surgery for patients with severe or persisting symptoms' below.)
Combination therapy — Although the evidence is limited, combined treatment consisting of splinting with glucocorticoid injection(s) may provide additional benefit for symptom management over either therapy alone [2,6,22-24].
●For patients who chose initial nocturnal splinting but remain symptomatic at one to two months, we continue splinting for another one to two months and add a different nonsurgical modality for CTS rather than stopping splinting. We suggest adding a glucocorticoid injection as the next therapeutic option; for patients who decline injection therapy, we suggest adding oral glucocorticoids. Other nonsurgical options may be added if oral glucocorticoids are not feasible. (See 'Glucocorticoid injection' above and 'Oral glucocorticoids' below and 'Other nonsurgical options' below.)
●For patients who chose initial glucocorticoid injection with partial improvement within one to two months, we suggest adding nocturnal splinting. For patients who decline splinting, we add other nonsurgical options. (See 'Wrist splinting' above and 'Other nonsurgical options' below.)
●For patients with a partial improvement by one to two months of combination therapy, we add other nonsurgical options. For patients who are unresponsive to combination nonsurgical therapies, we refer for surgical treatment. (See 'Other nonsurgical options' below and 'Surgery for patients with severe or persisting symptoms' below.)
When splinting and glucocorticoid injections are combined, symptom duration of less than three months and absence of sensory impairment at presentation may be predictive of a lasting response to nonsurgical treatment [25].
Oral glucocorticoids — Oral glucocorticoids may be used as an alternative to glucocorticoid injection, typically in combination with splinting or other nonsurgical therapies for patients with an inadequate response to initial therapy.
●Regimen – We use a short course of oral glucocorticoids, such as prednisone 20 mg daily for 10 to 14 days.
●Adverse effects – Oral glucocorticoid treatment should not extend beyond four weeks' duration because of the deleterious side effects of prolonged glucocorticoid therapy (table 2). These include gastritis, hyperglycemia, immune suppression, osteoporosis, and neuropsychiatric symptoms. (See "Major adverse effects of systemic glucocorticoids".)
Oral glucocorticoids appear to be effective for short-term improvement of CTS symptoms. In a 2003 systematic review, analysis of pooled data from three trials of high and moderate methodologic quality showed that two weeks of oral glucocorticoid treatment was associated with a reduction in symptoms by two weeks compared with placebo (weighted mean difference [WMD] -7.23, 95% CI -10.31 to -4.14) [26]. In a small trial that evaluated 60 patients with mild to moderate CTS, treatment with two weeks of oral prednisone (20 mg daily for seven days, followed by 10 mg per day for seven days) was associated with significant initial improvement in symptoms, but the benefit gradually waned over eight weeks of observation [27].
There are only limited data regarding the long-term benefit of oral glucocorticoids for treatment of CTS. In one clinical trial that evaluated two to four weeks of treatment with up to 20 mg per day of oral prednisolone, approximately half of patients showed clinical and electrodiagnostic improvement for up to 12 months [28]. However, this study did not have a placebo control group.
Oral glucocorticoids appear less effective than glucocorticoid injection. In a small clinical trial of 60 patients with CTS, patients assigned to a methylprednisolone 15 mg local injection reported greater improvement in symptoms than those assigned oral prednisolone 25 mg daily for 10 days at 2-, 8-, and 12-week follow up [29].
Other nonsurgical options — Limited and low-quality data suggest that yoga and carpal bone mobilization may be reasonable alternative options for nonsurgical treatment if available. Treatment options of possible but unproven benefit include nerve-gliding maneuvers and therapeutic ultrasound.
●Yoga – Limited evidence suggests that yoga may be beneficial for pain control in patients with CTS. A preliminary assessor-blinded controlled trial assigned 42 patients with CTS to eight weeks of treatment with yoga or to wrist splinting [30]. The yoga intervention consisted of 11 yoga postures designed for strengthening, stretching, and balancing each joint in the upper body along with relaxation administered twice weekly. Patients in the yoga group reported greater pain reduction and improved grip strength compared with patients in the wrist splint group at 8 weeks.
●Carpal bone mobilization – Carpal bone mobilization is a physical and occupational therapy technique that involves movement of the bones and joints in the wrist. Data are limited, but a small, unblinded trial involving 21 people found that carpal bone mobilization significantly improved symptoms (assessed using a symptom diary with a visual analog scale) after three weeks compared with no treatment [31,32]. However, there was no significant improvement in hand function.
●Nerve gliding – Nerve- and tendon-gliding exercises are maneuvers to improve nerve mobility, performed under the direction of an occupational therapist with subspecialty certification in hand therapy. Nerve gliding is aimed at restoring normal movement of the median nerve. It is thought that nerve compression may lead to "tethering" of the median nerve, resulting in decreased nerve excursion and increased mechanical strain [33]. Restricted movement of the median nerve has been observed in patients with CTS [2,33-36].
There is only limited and low-quality evidence regarding the efficacy of nerve- and/or tendon-gliding interventions for CTS [32]. As an example, a randomized, unblinded trial involving 36 patients with CTS assigned to wrist splinting found that patients additionally assigned to nerve- and tendon-gliding exercises for four weeks were likelier to report symptom improvement by a mean 8-month follow-up (93 versus 72 percent), but results were not statistically significant [23]. A subsequent assessor-blinded trial of 120 females with longstanding CTS compared physical therapy (nerve gliding and soft tissue mobilization maneuvers) with surgery and found that the two treatments resulted in similar outcomes at one year [37].
●Ultrasound therapy – Ultrasound is used to promote healing after nerve and tendon injuries and for the transdermal delivery of medications at intensities ranging from 0.5 to 1.5 watt/cm2 [38]. At its lower-intensity range, ultrasound can induce changes in cell permeability that are thought to enhance the healing response. At its upper range, ultrasound raises tissue temperature while reducing pain, increases tissue elasticity, and decreases tissue viscosity [38].
Data regarding the benefit of ultrasound for CTS are conflicting, although its effectiveness may depend on the duration of therapy. A 2013 systematic review concluded that the available data from clinical trials provide only low-quality evidence that ultrasound may provide symptom improvement in CTS [39]. In one of the included trials, ultrasound treatment for seven weeks led to modest symptom improvement at three and six months, but certainty in these data is limited by loss to follow-up in treatment groups [40].
The effectiveness of ultrasound may vary by the characteristics of the ultrasound used. Deep, pulsed ultrasound has been reported to decrease pain and improve sensory loss, nerve conduction parameters, and strength [40]. Continuous superficial ultrasound does not improve patients' symptoms or median nerve conduction parameters [6,41]. However, available data on ultrasound frequencies and intensities for CTS are insufficient to specify optimal treatment protocol [39].
Therapies not recommended
●NSAIDs and other oral medications – A 2003 systematic review [26] found one randomized controlled trial [42] that demonstrated no significant benefit for nonsteroidal antiinflammatory drugs (NSAIDs) compared with placebo for improving CTS symptoms. NSAIDs may also potentiate the risk of gastrointestinal adverse effects if used with oral glucocorticoids.
The utility of agents used for other neuralgias and painful neuropathies (eg, gabapentin, pregabalin) appears to be modest or negligible when used for CTS symptoms, and available studies are limited to patients with mild symptoms and short-term follow-up [43,44]. The available data also suggest no benefit for diuretics [26,42] or vitamin B6 [26] for CTS.
●Electrical, magnetic, and laser therapy – No clear hypotheses have been generated to support the use of any of these modalities for the treatment of CTS. Only anecdotal evidence exists regarding electrical stimulation for the treatment of CTS. A single session of magnetic therapy was not effective when compared with sham therapy [6,45], and prolonged magnetic therapy was not effective compared with placebo [6,26,46]. Similarly, the effectiveness of low-level laser therapy has not been proven in small controlled trials [47].
●Perineural dextrose injections – The possible benefit of perineural injections of dextrose 5% in water (D5W) was first supported by the results of a double-blind, randomized trial of 49 subjects with mild-to-moderate CTS [48]. Subjects were assigned to an ultrasound-guided perineural injection of D5W solution (5 mL) or saline, delivered to separate the median nerve from the flexor retinaculum, connective tissue, and flexor tendons through hydrodissection. At six months, the D5W group showed a reduction in pain and disability, improved electrophysiologic parameters, and decreased cross-sectional area of the median nerve compared with the placebo group. A follow-up trial carried out at the same center and with a similar design compared a single D5W injection with a triamcinolone injection in 54 patients with CTS [49]. At four- and six-month follow-up, the D5W group experienced greater reductions in measures of pain and functional disability compared with the glucocorticoid injection group. Limitations of both trials include small sample size and uncertain clinical significance of relatively small differences in outcome measures. These results need to be replicated before this option can be suggested outside of a clinical trial.
Pregnancy — CTS may develop during pregnancy, particularly during the third trimester [50,51]. In most cases, the symptoms gradually resolve over a period of weeks after delivery. For patients who develop CTS during pregnancy, we suggest nocturnal wrist splinting as initial therapy. Glucocorticoid injection or other nonsurgical options may be offered to pregnant patients if splinting is ineffective. Surgical decompression is rarely indicated during pregnancy since the disease often resolves postpartum. In a prospective case-control study of 45 pregnant patients with CTS and 90 controls (age-matched patients with idiopathic CTS) who were followed for three years, the pregnancy cohort was significantly more likely to show improvement in severity and function scores (68 and 73 percent, respectively) than the control cohort (42 and 39 percent) [52].
SURGERY FOR PATIENTS WITH SEVERE OR PERSISTING SYMPTOMS — Surgery is the treatment of choice for patients with evidence of ongoing severe nerve damage (table 1) in the absence of a reversible etiology.
Patient selection — For patients with moderate or severe symptoms and electrodiagnostic evidence of severe median nerve injury (denervation or axon loss) (table 1), we suggest referral for surgical intervention unless there is a clear temporary precipitating factor such as pregnancy. Clinical experience suggests that patients with significant evidence of nerve injury on electrodiagnostic studies (axonal degeneration on nerve conduction studies or denervation on needle electromyography) seldom benefit from splinting or other nonsurgical interventions for CTS.
Patients who lack evidence of significant axonal loss can be treated initially with nonsurgical measures (see 'Initial nonsurgical treatment for most patients' above). However, surgical decompression may be warranted for patients who lack evidence of axonal loss or denervation if symptoms do not respond to an adequate trial of nonsurgical measures. Predictors associated with failure of conservative/nonsurgical therapy include the following [2,3,53,54]:
●Long duration of symptoms (>6 to 12 months)
●Age greater than 50 years
●Continuous paresthesias
●Impaired two-point discrimination (>6 mm interval)
●Positive Phalen sign (within 30 seconds of hand positioning) (picture 1)
●Prolonged motor and sensory latencies demonstrated by electrodiagnostic testing
Preoperative electrodiagnostic confirmation — Electrodiagnostic studies should be obtained prior to surgical treatment (if not already performed during diagnostic evaluation) to confirm the diagnosis of CTS, to assess severity, and to guide appropriateness of surgery. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on 'Electrodiagnostic testing'.)
Surgical techniques for carpal tunnel — Surgery for CTS involves dividing the transverse carpal ligament (or flexor retinaculum) and the antebrachial fascia (figure 2 and figure 3) to reduce pressure on the median nerve. It may be performed by standard incision or endoscopically, with or without ultrasound guidance. (See "Surgery for carpal tunnel syndrome", section on 'Surgical techniques'.)
Efficacy of carpal tunnel surgery — Surgery appears to provide more durable, long-term benefit than nonsurgical regimens in properly selected patients [4,22,55-59].
●Surgery versus multimodal nonsurgical therapy – The effect of surgery was compared with nonsurgical therapy in a trial of 116 patients with moderate to severe CTS symptoms and moderate impairment on electrodiagnostic studies who did not respond to a trial of initial nonsurgical treatment [22]. Patients were assigned either to carpal tunnel surgery or to multimodal nonsurgical treatment (eg, wrist splinting, occupational therapy with a hand therapist, ultrasound, and nonsteroidal antiinflammatory drugs) [22]. The primary outcome was the change in functional status assessed by the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ), which rates severity on a scale of 1 to 5. Patients assigned to surgery had greater functional improvement on the CTSAQ when assessed at 6 months (-0.5, 95% CI 0.2-07) and 12 months (-0.4, 95% CI 0.1-0.7). In addition, patients who underwent surgery reported greater improvement in symptoms at 6 and 12 months.
●Surgery versus splinting – Surgical treatment of CTS appears to be more effective than splinting for long-term outcomes, although the evidence is somewhat limited [59]. One trial assigned 176 patients with CTS assigned either to nocturnal wrist splinting or surgical decompression [4]. Most patients had symptoms that were moderate in severity and chronic (>6 months). At one month, complete or marked improvement was greater with those treated with splinting than surgery (42 versus 29 percent). However, at one year, complete or marked improvement was greater in those treated with surgery compared with splinting (92 versus 72 percent). In the systematic review that included patient data from two additional trials, clinical improvement at three months was greater with surgery than with splinting (75 versus 57 percent) [59]. Pooled clinical improvement over the longer-term (6 to 12 months) was greater with surgery than splinting (93 versus 60 percent), but certainty of these results is limited by randomization bias in some studies.
●Surgery versus glucocorticoid injections – Limited data has shown similar or better outcomes with surgery than glucocorticoid injections. In one trial, 50 patients (48 were female) with CTS were assigned to a single injection of methylprednisolone 15 mg or open surgical carpal tunnel decompression [60]. At 20 weeks, surgical treatment led to reduced grip strength scores but significantly greater symptomatic improvement in the global symptom score (GSS) than local glucocorticoid injection (24 versus 9 points, respectively). In addition, surgical treatment resulted in significantly greater improvements in electrophysiologic outcomes (distal motor latency and sensory nerve conduction velocity) of the median nerve.
The short-term results of glucocorticoid injection may be better than those following carpal tunnel release surgery, but longer-term results appear similar [59]. A prospective open study randomly assigned 163 patients with symptomatic CTS to glucocorticoid injection into the carpal tunnel (20 mg of paramethasone acetonide) or surgical release (via a limited palmar incision) [61]. The main outcome was the proportion of patients in each group who had at least 20 percent improvement in nocturnal paresthesias. Improvement in nocturnal paresthesias at three months was greater in those assigned to injection (94 versus 75 percent), but the difference waned by 12 months (76 versus 75 percent).
The reported complication rates with surgery are variable and likely reflect differences in training and experience. (See "Surgery for carpal tunnel syndrome", section on 'Complications'.)
Persistent symptoms after surgical decompression — Persistent symptoms of CTS after decompression surgery may be caused by circumferential fibrosis or by reconstitution or incomplete release of the transverse carpal ligament (see "Surgery for carpal tunnel syndrome", section on 'Complications'). In such cases, revision surgery may be performed [62].
PROGNOSIS — Treatment of CTS with nonsurgical measures or surgical decompression varies by symptom severity but may lead to complete or marked improvement in 70 to 90 percent of patients by one year [59].
The natural history of CTS is not well defined. One study of nearly 200 untreated patients with CTS reported that the symptoms of patients with minimal or mild compression tended to worsen without treatment over 10 to 15 months, while those with initially moderate or severe involvement tended to improve [63]. Among the factors that predicted progression were a positive Phalen test and bilateral disease.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Carpal tunnel syndrome".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Carpal tunnel syndrome (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Treatment approach – Our approach to the management of patients clinically diagnosed with carpal tunnel syndrome (CTS) is based on the severity of symptoms and electrodiagnostic features (algorithm 1). (See 'Assess the severity of symptoms and nerve injury' above.)
●Pretreatment assessment – CTS symptoms can be categorized as mild, moderate, or severe (table 1). (See 'Assess the severity of symptoms and nerve injury' above.)
For patients with moderate or severe CTS symptoms, electrodiagnostic testing is performed when surgical intervention is considered to confirm the clinical diagnosis and to define the extent of median nerve injury. Electrodiagnostic criteria can be used to discriminate among mild, moderate, or severe CTS (table 1).
●Mild to moderate disease – For patients with mild to moderate symptoms and no electrodiagnostic features suggesting axonal loss, we suggest nocturnal wrist splinting in the neutral position or a glucocorticoid injection rather than surgical intervention (Grade 2C). We also treat other patients with moderate to severe symptoms and electrodiagnostic features of consistent with mild or moderate CTS (without axon loss) with initial nonsurgical measures. (See 'Initial nonsurgical treatment for most patients' above.)
•Initial therapy – Splinting may be selected by patients with mild symptoms and those who prefer a noninvasive approach. Glucocorticoid injection may be preferred by those who prioritize faster onset of symptom relief or who are unwilling to adhere to a regimen of wrist splinting.
-Wrist splints are usually worn at night, but they can be worn continuously. A trial of one to two months is reasonable to assess benefit of symptom relief. (See 'Wrist splinting' above.)
-Glucocorticoids may be administered by a single injection of methylprednisolone (20 to 40 mg) with 1% lidocaine. We limit the frequency of glucocorticoid injections for patients with symptom recurrence to no more than once every six months per wrist. (See 'Glucocorticoid injection' above.)
•Additional options if initial therapy is ineffective – For patients with partial or transient improvement with either splinting or glucocorticoid injection initial nonsurgical therapy, we offer combination therapy with both measures. For patients with symptoms that are partially responsive to splinting and glucocorticoids, we add other nonsurgical options. If symptoms persist or worsen despite nonsurgical therapy, we refer for surgical intervention. (See 'Additional nonsurgical options if initial therapy is ineffective' above.)
●Severe disease – For most patients with moderate or severe symptoms and electrodiagnostic evidence of severe median nerve injury (denervation or axon loss) (table 1) and for those with symptoms that are unresponsive to nonsurgical treatment, we suggest referral for surgical intervention (Grade 2C). Other patients with clear temporary precipitating factor such as pregnancy and those who lack evidence of significant axonal loss or denervation can be treated initially with nonsurgical measures. (See 'Surgery for patients with severe or persisting symptoms' above.)
●Prognosis – The natural history of untreated CTS is not well defined. Most patients improve with treatment by one year. (See 'Prognosis' above.)
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