Guidelines provided by the New York State Workers Compensation Board offer essential principles for addressing Carpal Tunnel Syndrome (CTS). These directives are formulated to aid healthcare professionals in determining appropriate interventions for CTS within the framework of a comprehensive assessment.
Healthcare experts specializing in managing Carpal Tunnel Syndrome can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic approaches for their patients.
It is crucial to highlight that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding interventions for Carpal Tunnel Syndrome should involve collaboration between the patient and their healthcare provider.
Carpal Tunnel Syndrome (CTS)
CTS, the most prevalent and widely recognized entrapment neuropathy, involves the compression or trauma of peripheral nerves in the body. The onset of CTS is marked by symptoms linked to abnormal compression of the median nerve within the carpal tunnel. The median nerve is responsible for sensations in the palmar aspect of the thumb, index and middle fingers, as well as the radial half of the ring finger, and the dorsal segment of each of these digits distally from the DIP. Key symptoms include tingling and numbness, while pain is not obligatory and, if present, might suggest other conditions, potentially radiating proximally. Frequently, CTS emerges without an apparent cause.
Numerous conditions, such as inflammatory or non-inflammatory arthropathies, recent or past wrist trauma or fractures, diabetes mellitus, obesity, hypothyroidism, pregnancy, and genetic factors, can lead to CTS. In rare cases where CTS is acutely induced by trauma, like a patient with both CTS and concurrent trauma (fracture or dislocation), prompt carpal tunnel release may be necessary. Patients with open injuries, unstable fractures, or acute CTS resulting from wrist fractures require immediate referral to a surgeon, as surgical intervention may be the only viable solution for improvement.
Medical History
A diagnosis of CTS is based on symptoms indicative of median nerve entrapment at the wrist, supported by physical examination findings. Confirmation through electrodiagnostic studies (EDX) is necessary before surgery. Typical CTS symptoms include numbness, tingling, or pain in the volar aspects of one or both hands, especially after work or at night.
Nocturnal symptoms are common, with patients often waking up at night and shaking their hands for relief. Symptoms may be reported as affecting the entire hand or localized to the palmar surfaces of specific fingers. A hand pain diagram can assist in pinpointing sensory symptoms of CTS. Signs such as hand weakness or dropping objects may suggest muscle damage, necessitating prompt consideration of EDX and surgical treatment.
Medical conditions associated with CTS, requiring treatment and potentially impacting the recovery of work-related injuries, include: a. Arthropathies like connective tissue disorders, rheumatoid arthritis, systemic lupus erythematosus, gout, osteoarthritis, and spondyloarthropathy; b. Diabetes mellitus, including family history or gestational diabetes; c. Hypothyroidism, particularly in older females; d. Obesity; e. Pregnancy.
Physical Exam
No singular physical finding serves as a definitive diagnostic indicator for CTS. The ultimate diagnosis relies on a correlation of symptoms, physical examination findings, and appropriate EDX testing, given that any of these factors alone can yield false positives or negatives. Evaluating a patient with suspected CTS should commence from the neck and upper back, progressing down to the fingers and including the contralateral region.
It should encompass an assessment of vascular and neurologic status, as well as the identification of dystrophic changes or variations in skin color or turgor. Depending on past medical history, additional components of the physical examination may be necessary. A neurological examination typically involves bilateral evaluations of light touch sensation, pinprick, two-point sensation as applicable, motor strength, and reflexes.
Similar assessments may extend to the upper extremities, accompanied by a vascular assessment. Particular attention should be paid to assessing for polyneuropathic processes, such as diabetic neuropathy.
Clinical suspicion of CTS arises when a patient has a history of paresthesia in the thumb, index, and middle finger, combined with at least one of the listed physical exam signs below. Provocative tests must induce symptoms in the median nerve distribution, including:
– Phalen’s sign/reverse Phalen’s sign.
– Tinel’s sign over the carpal tunnel.
– Compression test.
– Weakness of the abductor pollicis brevis (refer to EDX studies).
– Possible late-stage presentation of thenar atrophy (refer to EDX studies).
– Sensory loss in pinprick, light touch, two-point discrimination, or Semmes Weinstein monofilament test within a median nerve distribution.
Clinical exam tests for CTS may involve:
– Monofilament test: Involves nylon monofilaments that collapse at specific force levels when pushed against the palm or fingers. A positive test occurs when a larger-than-normal filament is required for the patient to perceive its application.
– Vibration Testing: Assessing the ability to perceive vibratory sensations using a standard vibrating tuning fork, comparing the distal interphalangeal joint of the index finger to the ipsilateral fifth finger.
– Weak thumb abduction strength: Evaluating weakness of resisted abduction with the palm horizontal, thumb lifted vertically, and the patient resisting the examiner pushing the thumb down toward the index finger.
– Hoffmann-Tinel’s Sign (“Tinel’s”): Involves up to six taps of a reflex hammer or the examiner’s finger tip to the soft tissue overlying the carpal tunnel. A positive test occurs when taps induce paresthesias or shooting pain in the median nerve distribution.
– Phalen Sign: Originally described as passive wrist flexion by the examiner for up to 60 seconds. More commonly performed with the patient pressing the dorsal aspect of both hands together with approximately 90 degrees of flexion for 60 seconds. A positive test results in paresthesias in the affected median nerve distribution.
– Carpal Compression Test: The examiner holds the supinated wrist in both hands, flexes the wrist 45 degrees, and applies direct, even pressure over the transverse carpal ligament with both thumbs for up to 30 seconds. A positive test is indicated by tingling or paresthesia in the thumb, index finger, and middle and lateral half of the ring finger within 30 seconds.
Diagnostic Studies
Electrodiagnostic Studies
In cases where EDX studies are deemed necessary, they should align with the CTS practice parameters set by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). It is strongly advised that physicians board-certified in Neurology or Physical Medicine and Rehabilitation perform and interpret EDX studies in an outpatient setting. The study should encompass median motor and median sensory nerve conduction velocity results (NCV).
If abnormal, a comparison with ipsilateral ulnar motor/sensory and contralateral median motor/sensory should be made. Needle electromyography (EMG) of muscles innervated by the C5 to T1 spinal roots, including paraspinal muscles and a thenar muscle innervated by the median nerve of the symptomatic limb, is mandatory. EDX findings in CTS indicate a slowing of median motor distal latency and sensory conduction velocity across the carpal tunnel region, attributed to demyelination or axonopathy (axonal loss).
NCS and EMG may appear normal, especially in milder CTS cases. If EDX results are negative, repeating tests later in the treatment course may be considered if symptoms persist. It is crucial to acknowledge that electrodiagnostic studies may show abnormalities in a significant proportion of asymptomatic patients without CTS. Consequently, EDS testing in patients with a low pre-test probability of CTS may lead to an incorrect diagnosis. EDS has limited utility in diagnosing clear-cut CTS cases.
Frequency of NCV/EMG Studies/Maximum Number of Studies
- Indications for initial testing: a. Patients with clinically significant CTS not improving with conservative measures over 3 to 4 weeks. b. Patients with a doubtful diagnosis who have been symptomatic for at least 3 weeks. c. To rule out other nerve entrapments or alternative radiculopathy. d. Patients considering surgery as per Section F.1.
- Repeat study may be performed: a. At 3 months or later if initial studies were normal, and CTS is still suspected. b. Postoperative 8 to 12 weeks for persistent or recurrent symptoms following carpal tunnel release, unless earlier evaluation is necessary.
For patients with CTS where electrodiagnostic confirmation would alter treatment plans, the following EDS studies are recommended:
- Warm the hands if <30°C; maintain temperatures above 32°C.
- Perform a median sensory NCS across the wrist (conduction distance: 13 to 14 cm). If abnormal, compare to an adjacent sensory nerve’s result in the symptomatic limb.
- If the initial median sensory NCS across the wrist has a conduction distance exceeding 8 cm and normal results, consider additional studies. a. Compare median-sensory or mixed-nerve conduction across the wrist to ulnar sensory-nerve conduction over a short (7 to 8 cm) distance. b. Compare median sensory across the wrist with ipsilateral radial or ulnar sensory conduction across the wrist. c. Compare median sensory or mixed nerve conduction through the carpal tunnel to sensory or mixed NCS of proximal or distal segments of the ipsilateral median nerve.
- Perform a motor conduction study of the median nerve, recording from the thenar muscle and one other ipsilateral nerve with distal latency.
- Optional comparisons may include ipsilateral median-ulnar motor nerve distal latencies and median-ulnar motor conduction differences.
- If abnormal in the index limb, measuring the contralateral limb is helpful for comparison and diagnosing systemic disorders.
Electrodiagnostic Studies Not Recommended:
- For initial evaluation in most patients with a clear diagnosis of CTS, as it won’t alter the treatment plan. Recommended:
- To secure a firm diagnosis for patients without a clear diagnosis of CTS and to identify the presence or absence of axonopathies.
- To definitively evaluate and objectively secure a diagnosis of CTS before surgical release. Rationale: to assist in the diagnosis, prognosis, and management of CTS. Frequency: a repeat study at three months may be indicated if the first study was not diagnostic and CTS is still suspected. EDS is also indicated at 8-12 weeks post-operatively in cases where results are inadequate and/or symptoms have recurred. Not Recommended:
- Prior to glucocorticosteroid injection, as a good history and clinical suspicion are believed to be sufficient for the intervention, not likely altered by EDS.
- The use of hand-held automated devices or portable automatic devices is not recommended and not acceptable to confirm a clinical diagnosis of CTS.
- Surface EMG is not recommended in the diagnostic evaluation of CTS.
Ultrasound (Diagnostic)
Not Recommended – for diagnosing CTS. Recommended in very select cases where a space-occupying lesion is suspected, and MRI is contraindicated.
Magnetic Resonance Imaging (MRI)
Not Recommended – for the evaluation and diagnosis of CTS. Recommended in very select cases where a space-occupying lesion is suspected.
Initial Treatment
Initial treatment of CTS should commence with conservative measures, including:
– Medications such as over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) or other analgesics for symptomatic relief.
– Wrist splint at night.
– Restriction of activities such as forceful gripping, awkward wrist posture, and repetitive wrist motion.
Wrist Splinting
Splinting is generally effective for milder cases of CTS and can lead to more improvement in symptoms and hand function than watchful waiting alone. Splints may be effective when worn during sleep hours or during portions of the day, depending on work activities.
Splints should be loose and soft enough to maintain comfort while supporting the wrist in a relatively neutral position. This can be accomplished by using a soft or rigid splint with a metal or plastic support. Off-the-shelf splints are usually sufficient, although custom thermoplastic splints may provide a better fit for certain patients. Providers should be aware that over-usage is counterproductive and should counsel patients to avoid over-usage.
Recommended – nocturnal wrist splinting for the treatment of acute, subacute, or chronic CTS.
Recommended – intermittent daytime splinting for select patients depending on job activities.
Indications – Symptoms consistent with carpal tunnel syndrome.
Frequency/Dose – Wrist splints are recommended to be worn while sleeping for 4 to 6 weeks. Depending on job activities, intermittent daytime splinting can also be helpful. The time to produce effect is 1 to 4 weeks.
Discontinuation – Splints should be reevaluated and readjusted as indicated if no response within 2 weeks of starting treatment, particularly to ensure that the patient is wearing them properly as well as to assess fit. If symptoms persist or if there is no improvement, splints should be discontinued, and glucocorticosteroid injection and/or electrodiagnostic testing may be considered.
Patient Education
Instruction in self-management techniques, including sleeping postures that avoid excessive wrist flexion; ergonomics; and a home therapy program.
Continuation of Activities
Continuation of normal daily activities is an accepted and well-established initial recommendation for CTS with or without neurologic symptoms. Complete work cessation should be avoided if possible.
Work Activities
All patients should be encouraged to return to work as soon as possible. This process may be best facilitated with modified duty, particularly when the job demands exceed the patient’s capabilities due to the workplace injury. It is recommended that work be restricted to those tasks that do not involve high-force combined with repeated hand gripping or pinching or the use of high acceleration vibrating handheld tools. Recommendations for ergonomic assessments to evaluate or reduce exposure may be of value for treatment and future intervention/prevention.
Diagnosis
To establish a diagnosis of work-related carpal tunnel syndrome, the following criteria are essential:
- Exposure: Workplace activities contributing to or causing CTS.
- Outcome: CTS meeting the diagnostic criteria as defined in this guideline.
- Relationship to work: A statement assessing the probability of work-relatedness. The presence of concurrent disease doesn’t eliminate the possibility of work-relatedness. Work-related CTS is often associated with extensive, forceful, repeated, or prolonged use of hands and wrists, especially if these factors occur in combination (e.g., force and repetition or force and posture). Regular occurrence of one or more of the following work conditions supports work-relatedness:
- Forceful use, especially if repeated.
- Repetitive hand use combined with some force, particularly for prolonged periods.
- Constant firm gripping of objects.
- Movement or use of the hand and wrist against resistance or with force.
Medications
For most patients, first-line medications include ibuprofen, naproxen, or other older-generation NSAIDs. Acetaminophen (or paracetamol) may be an alternative for patients not suitable for NSAIDs, though evidence suggests it is slightly less effective. NSAIDs are shown to be as effective as opioids (including tramadol) for pain relief and less impairing.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic CTS
Recommended – for the treatment of acute, subacute, or chronic CTS. Indications – NSAIDs are recommended for acute, subacute, or chronic CTS. Over-the-counter (OTC) agents may be sufficient and should be attempted first. Frequency/Duration: As-needed use may be reasonable for many patients. Indications for Discontinuation: Resolution of symptoms, lack of efficacy, or development of adverse effects requiring discontinuation.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended – for concomitant use of cytoprotective drugs: misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors for patients at high risk of gastrointestinal bleeding. Indications: Consider cytoprotective medications for patients with a high-risk factor profile requiring NSAIDs, especially for longer-term treatment. At-risk patients include those with a history of prior gastrointestinal bleeding, elderly individuals, diabetics, and cigarette smokers. Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers recommended. Dose and frequency per manufacturer. No substantial differences in efficacy for preventing gastrointestinal bleeding. Indications for Discontinuation: Intolerance, adverse effects, or discontinuation of NSAID.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with known cardiovascular disease or multiple risk factors should discuss the risks and benefits of NSAID therapy for pain. Recommended – Acetaminophen or aspirin as first-line therapy appears to be the safest regarding cardiovascular adverse effects. Recommended – If needed, non-selective NSAIDs are preferred over COX-2 specific drugs. For patients receiving low-dose aspirin, NSAIDs should be taken at least 30 minutes after or 8 hours before the daily aspirin to minimize potential counteraction of aspirin’s beneficial effects.
Acetaminophen for Treatment of CTS Pain
Recommended – for the treatment of CTS pain, especially in patients with contraindications for NSAIDs. Indications: All patients with CTS pain, including acute, subacute, chronic, and post-operative. Dose/Frequency: Per manufacturer’s recommendations; may be utilized on an as-needed basis. Evidence of hepatic toxicity when exceeding four gm/day. Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
Systemic Glucocorticosteroids
Recommended – in specific cases for treating Acute, Subacute, or Chronic CTS among patients unwilling to undergo carpal tunnel injection.
Indication – CTS unresponsive to splinting. For patients declining injection, oral glucocorticosteroids may be considered, although most patients are better suited for injection.
Frequency/Dose: A single course (10 to 14 days) of oral glucocorticosteroid is recommended instead of repeated courses. Prescribing lower doses is advised to minimize potential adverse effects.
Diuretics
Diuretics have been employed to address CTS, partly due to observed swelling in some patients.
Not Recommended – for treating acute, subacute, or chronic CTS in the absence of fluid retention states.
Opioids
Not Recommended – for acute, subacute, or chronic CTS.
Recommended – for limited use (up to seven days) in postoperative pain management as an adjunct to more effective treatments.
Indications: Brief opioid prescription for post-operative pain management, used alongside more efficacious treatments (especially NSAIDs, acetaminophen), particularly at night.
Frequency/Duration: As needed throughout the day, later reduced to nighttime use before tapering off.
Rationale for Recommendation: Some patients may not achieve sufficient pain relief with NSAIDs; thus, judicious use of opioids, especially nocturnally, may be beneficial. Recommended for brief, selective use in postoperative patients, primarily at night for postoperative sleep.
Vitamins (including pyridoxine)
Not Recommended – for routine treatment of acute, subacute, or chronic CTS in patients without vitamin deficiencies.
Lidocaine Patches
Recommended – in specific cases for treating acute, subacute, or chronic CTS pain when other treatable causes have been ruled out and after attempting more effective treatments such as splinting and glucocorticosteroid injections that proved unsuccessful.
Indications for Discontinuation – Resolution, intolerance, adverse effects, lack of benefits, or failure to progress over a trial of at least two weeks.
Gabapentin
Not Recommended – for treating carpal tunnel syndrome.
Rehabilitation
Rehabilitation following a work-related injury should focus on restoring functional abilities for the patient’s daily and work-related tasks, aiming to bring the injured worker back to a pre-injury status where possible. Active therapy involves internal efforts by the patient to complete specific exercises or tasks, while passive therapy relies on interventions administered by a therapist.
Generally, passive interventions are considered a means to facilitate progress in an active therapy program and achieve objective functional gains. Prioritizing active interventions over passive ones is recommended. Patients are advised to continue both active and passive therapies at home as an extension of the treatment process to maintain improvement levels. Assistive devices may be included in the rehabilitation plan as adjunctive measures to facilitate functional gains.
Therapy – Active
Therapeutic Exercise
Various exercise regimens have been used to treat patients with CTS. Recommended for treating chronic CTS in the presence of functional deficits. Recommended for rehabilitating post-operative CTS in patients with stiffness and significant deficits.
Frequency/Dose/Duration – The total number of visits may range from two to three for patients with mild functional deficits to 12 to 15 for those with more severe deficits, with documentation of ongoing objective functional improvement.
If ongoing functional deficits persist, more than 12 to 15 visits may be indicated, provided there is documentation of functional improvement towards specific objective goals (e.g., increased grip strength, key pinch strength, range of motion, advancing ability to perform work activities). A home exercise program should be developed and performed in conjunction with therapy as part of the rehabilitation plan.
Yoga
Not recommended for treating acute, subacute, or chronic CTS.
Biofeedback
Not recommended for treating acute, subacute, or chronic CTS.
Therapy – Passive
Cryotherapy / Heat
Ice / Self-Applied Ice
Recommended for treating acute, subacute, or chronic CTS.
Heat / Self-Applied Heat
Recommended for treating acute, subacute, or chronic CTS.
Diathermy
Not recommended for treating acute, subacute, or chronic CTS.
Manipulation and Mobilization
Not recommended for treating acute, subacute, or chronic CTS.
Manipulation of the Spine for Acute, Subacute, or Chronic CTS
Not recommended for treating acute, subacute, or chronic CTS.
Acupuncture
Not recommended for treating acute, subacute, or chronic CTS.
Devices
Magnets
Not recommended for managing pain from acute, subacute, or chronic CTS.
Pulsed Magnetic Field Therapy
Not recommended for managing pain from acute, subacute, or chronic CTS.
Low Level Laser Therapy (LLLT)
Not recommended for treating acute, subacute, or chronic CTS.
Massage and Soft Tissue Massage
Not recommended for most patients for treating acute, subacute, or chronic CTS.
Recommended for treating select patients with acute, subacute, or chronic CTS who have significant myofascial pain. Indications – Symptoms of carpal tunnel syndrome combined with forearm myofascial pain sufficient for the patient to require treatment. Generally, the patient should have failed other treatments, including splints and glucocorticosteroid injection.
Frequency/Dose – Three to four visits. Objective evidence of improvement should be documented. Additional 3 or 4 treatments should be based on incremental improvement in objective measures. Discontinuation – Resolution, failure to objectively improve, or intolerance.
Therapeutic Touch
Not recommended for treating acute, subacute, or chronic CTS.
Ultrasound
Not recommended for treating acute, subacute, or chronic CTS.
Phonophoresis
Recommended for treating acute, subacute, or chronic CTS. Indications – CTS that is sufficiently symptomatic to warrant treatment. Patients should generally be given splints and/or a glucocorticosteroid injection before considering phonophoresis, as a splint or injection is believed to be more effective. Frequency – 5-15 sessions per week for 4-8 weeks. Discontinuation – Resolution, failure to objectively improve, or intolerance.
Iontophoresis
Not recommended for use in treating acute, subacute, or chronic CTS.
Injection Therapy
Carpal Tunnel Steroid Injections
Recommended for treating subacute or chronic CTS with mild EMG findings. Recommended in select patients with moderate to severe EMG findings for temporary relief while awaiting surgery. Indications – CTS unresponsive to nocturnal wrist splinting, generally with symptoms lasting at least three weeks.
Frequency/Duration – An initial injection with documented improvement, even short-term, is believed to have considerable prognostic significance. If the initial steroid injection provides three to four weeks of partial relief or complete symptom relief but with recurrence of symptoms, a second injection may be indicated. If the second injection provides three to four weeks of partial or complete relief, surgical release may be indicated.
Failure to respond, particularly if the median nerve was successfully anesthetized by the injection, should result in a careful reassessment of the accuracy of the diagnosis of CTS. Patients who respond to carpal tunnel injections and develop recurrent symptoms are believed to be candidates for surgical release.
If, following the first injection, symptomatic relief is followed by recurrent symptoms, the decision to perform a second injection must be weighed against alternative treatments such as surgery. Surgical release may give more definitive relief of symptoms.
Carpal Tunnel Steroid Injections for the Treatment of Acute, Traumatic CTS without Fracture
Recommended for the treatment of acute CTS (without fractures) unresponsive to conservative management with symptoms lasting at least 3 weeks.
Acute CTS with fractures should be referred for potential emergent surgical release.
Carpal Tunnel Steroid Injections for the Treatment of Non-Traumatic CTS Due to Acute, Repetitive Overload Injury
Recommended for the treatment of non-traumatic CTS due to acute, repetitive overload injury.
In patients who decline injection, oral steroids may be an alternative
Intramuscular Injections
Not recommended for the treatment of acute, subacute, or chronic CTS.
Insulin
Not recommended for the treatment of acute, subacute, or chronic CTS.
Botulinum Injections
Not recommended for the treatment of acute, subacute, or chronic CTS.
Surgery
Surgical consultation may be warranted for CTS patients who meet any of the following criteria:
- Exhibit red flags of a serious nature.
- Fail to respond to non-surgical management, including worksite modifications.
- Present clear clinical and special study evidence of a lesion proven to benefit from surgical intervention in both the short and long term.
Decisions regarding surgery depend on the confirmed diagnosis of the presenting hand or wrist complaint. If surgery is being considered, it is crucial to provide counseling regarding likely outcomes, risks, benefits, and expectations. The most significant factor predicting symptomatic improvement post-carpal tunnel release is the severity of preoperative neuropathy.
If there is no clear indication for surgery, the patient should be referred for conservative management. Surgical intervention should be contemplated as initial therapy in the following situations:
- “Acute Carpal Tunnel Syndrome”: Immediate surgical referral is necessary for patients with open injuries, unstable fractures, or wrist fractures resulting in acute CTS, as improvement may only be achieved through surgery.
- Presence of thenar atrophy due to median nerve compression.
- Electrodiagnostic evidence of moderate to severe compressive neuropathy of the median nerve. EMG findings indicating acute or chronic motor denervation suggest possible irreversible damage.
For cases with positive EDX findings and a motor latency less than 5.0 ms, non-surgical treatment may be beneficial in some instances. Therefore, conservative management, including job alterations, should be attempted over four to six weeks before considering surgery.
Surgical Release
Recommended for patients with sub-acute or chronic CTS and moderate to severe EMG findings. Recommended for patients with subacute or chronic CTS with mild EMG findings who experience recurrent symptoms after partial or complete relief (3-4 weeks) with glucocorticosteroid injections.
Rationale/Indications: Failure of non-operative treatment, including two glucocorticosteroid injections. If the initial steroid injection provides 3 to 4 weeks of partial relief or complete symptom relief but with recurrence of symptoms, a second injection may be indicated. If the second injection provides 3 to 4 weeks of partial or complete relief, surgical release may be indicated.
Patients initially responding to corticosteroid injections and developing recurrent symptoms are considered candidates for surgical release. If symptomatic relief after the first injection is followed by recurrent symptoms, the decision to perform a second injection should be carefully weighed against alternative treatments such as surgery. Surgical release may offer more definitive relief of symptoms.
Recommended for patients with emergent or urgent indications (e.g., acute compression due to fracture, arthritides, or compartment syndrome with unrelenting symptoms of nerve impairment).
Rationale/Indications: Patients should undergo an electrodiagnostic study (EDS) consistent with CTS (see Electrodiagnostic Studies). Mild CTS with normal EDS exists, but a clinical impression of moderate or severe CTS with normal EDS is very rare and generally indicates a mistaken diagnosis. Positive EDS in asymptomatic individuals is common but not indicative of CTS, suggesting the need to carefully select patients for EDS and properly interpret the results.
Re-operation is potentially indicated if there is: (i) recurrence of symptoms after surgical release, (ii) electrodiagnostic findings are supportive at 8-12 weeks after surgical release, or (iii) re-exposure to work factors is not explanatory and remediable; those not improving after an initial surgery should undergo a thorough diagnostic workup.
Open or Endoscopic Release
Recommended for the treatment of subacute or chronic CTS. The choice between open or endoscopic release depends on the surgeon’s evaluation and discretion.
Antibiotics for Patients Undergoing Carpal Tunnel Release
Not recommended for routine use.
Antibiotics for Post-Operative Infection
Recommended as clinically indicated.
Other Adjunctive Procedures or Techniques for Subacute or Chronic CTS
Epineurotomy
Not recommended.
Internal Neurolysis
Not recommended.
Flexor Retinacular Lengthening
Not recommended.
Ulnar Bursal Preservation
Not recommended.
Altering the Location of the Incision to “Superficial Nerve-Sparing Incision”
Not recommended.
Ulnar Incisional Approach
Not recommended.
Flexor Tenosynovectomy
Not recommended.
Biopsy of Abnormal Tenosynovium
Not recommended for the treatment of subacute or chronic CTS.
