Treatment of Carpal Tunnel Syndrome (CTS)

1. Conservative (Non-operative) Treatment

• The first-line treatment for mild-to-moderate CTS. The wrist is held in a neutral position (not more than 10 degrees of extension).
• Splints are best prescribed for nighttime use to prevent provocative wrist positioning during sleep. Daytime use should be limited to avoid secondary muscle weakness and fatigue.
• "Off the shelf" splints often need adjustment to neutral before use.
• Effective for symptom relief, but long-term effectiveness is limited for moderate-to-severe cases. (Firestein & Kelley's Textbook of Rheumatology)

• Oral NSAIDs (e.g., ibuprofen) are used for pain control as an adjunct to splinting.
• They do not alter the underlying nerve compression but help manage symptoms.

• Avoiding repetitive forceful finger/wrist flexion-extension, vibrating tools, and sustained wrist flexion positions.

• 100-200 mg/day has been reported helpful in some cases, but efficacy has not been confirmed in randomized controlled trials. (Firestein & Kelley's Rheumatology)

2. Corticosteroid Injection

• Methylprednisolone (or other corticosteroids) injected locally into the carpal tunnel can provide effective short-term relief.
• Long-term efficacy is mixed; symptoms frequently recur.
• Risk of permanent median nerve injury if performed incorrectly - hence this requires proper technique.
• Best indicated when:
  • The condition is thought to be temporary (e.g., pregnancy-related CTS)
  • Surgery must be deferred due to medical conditions
  • Bridging therapy while awaiting definitive treatment
• 5% dextrose injection is an emerging alternative supported by recent evidence (Goldman-Cecil Medicine).

3. Physical Therapy and Other Conservative Modalities

• Nerve and tendon gliding exercises
• Carpal bone mobilization
• Ultrasound therapy and low-level laser therapy (LLLT)
• Extracorporeal shockwave therapy (ESWT) - gaining evidence support
• Platelet-rich plasma (PRP) injections - newer approach showing promise in studies

4. Surgical Treatment - Carpal Tunnel Release (CTR)

• Failure to respond to a full course of conservative treatment
• Late findings of objective sensory loss, thenar atrophy, or weakness - early surgery should be recommended in these patients rather than prolonged conservative management
• Persistent or recurrent symptoms after corticosteroid injections

• The endoscopic approach is generally preferred (Goldman-Cecil Medicine) due to faster return to activities and less scar tenderness, though outcomes at 6-12 months are equivalent to open release.
• Wide-awake local anesthesia no tourniquet (WALANT) surgery is an increasingly used technique, reducing costs and risks compared to sedation.
• Ultrasound-guided percutaneous CTR is a newer minimally invasive technique still under evaluation.

• Division of the transverse carpal ligament (TCL) decompresses the median nerve.
• The incision parallels the thenar crease to avoid the palmar cutaneous branch of the median nerve and reduce scar sensitivity.
• Synovectomy of the flexor tendons may be performed if hypertrophic synovitis is present.

• Most patients get excellent relief of pain and paresthesias.
• Thenar atrophy and objective weakness may improve but recovery is slower and depends on duration of compression before surgery.
• Early surgery is recommended when severe neurological signs are present - do not wait in these cases.

5. Treatment of Underlying Conditions

• Hypothyroidism - thyroid replacement therapy
• Diabetes mellitus - glycemic optimization
• Pregnancy-related CTS - usually resolves after delivery; splinting and injections bridge treatment
• Rheumatoid arthritis - treatment of synovitis reduces tunnel pressure
• Obesity - weight management

Summary Algorithm

Mild-Moderate CTS
    ↓
Wrist splinting (neutral, mainly nocturnal) + NSAIDs
    ↓ (if insufficient after 4-6 weeks)
Corticosteroid injection ± physical therapy
    ↓ (if failed conservative treatment OR severe/progressive)
Surgical carpal tunnel release (endoscopic preferred)

Note: In patients with objective sensory loss or thenar atrophy at presentation, skip prolonged conservative management and proceed to early surgery to prevent permanent nerve damage.