Carpal tunnel syndrome: Treatment and prognosis
- Milind J Kothari, DO
Milind J Kothari, DO
- Professor of Neurology
- Penn State College of Medicine
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. 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 review will discuss treatment of CTS. We will also briefly review the etiology, clinical features, and diagnosis of CTS, which are discussed in greater detail separately. (See "Carpal tunnel syndrome: Etiology and epidemiology" and "Carpal tunnel syndrome: Clinical manifestations and diagnosis".)
The carpal tunnel is formed by the transverse carpal ligament (flexor retinaculum) superiorly and the carpal bones inferiorly (figure 1). The median nerve, accompanied by the nine flexor tendons of the forearm musculature, must pass through this anatomic tunnel (figure 2). (See "Carpal tunnel syndrome: Etiology and epidemiology", section on 'Anatomy'.)
The pathophysiology of CTS is multifactorial. Increased pressure in the intracarpal canal is thought to play a key role in the development of clinical CTS. (See "Carpal tunnel syndrome: Etiology and epidemiology", section on 'Pathophysiology'.)
The hallmark of classic CTS is pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit (figure 3). The symptoms are typically worse at night and characteristically awaken affected patients from sleep. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on 'Clinical features'.)
- McClure P. Evidence-based practice: an example related to the use of splinting in a patient with carpal tunnel syndrome. J Hand Ther 2003; 16:256.
- Muller M, Tsui D, Schnurr R, et al. Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review. J Hand Ther 2004; 17:210.
- Akalin E, El O, Peker O, et al. Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises. Am J Phys Med Rehabil 2002; 81:108.
- Rozmaryn LM, Dovelle S, Rothman ER, et al. Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. J Hand Ther 1998; 11:171.
- Kaplan SJ, Glickel SZ, Eaton RG. Predictive factors in the non-surgical treatment of carpal tunnel syndrome. J Hand Surg Br 1990; 15:106.
- Stahl S, Yarnitsky D, Volpin G, Fried A. [Conservative therapy in carpal tunnel syndrome]. Harefuah 1996; 130:241.
- Mosier BA, Hughes TB. Recurrent carpal tunnel syndrome. Hand Clin 2013; 29:427.
- Gerritsen AA, de Vet HC, Scholten RJ, et al. Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. JAMA 2002; 288:1245.
- Verdugo RJ, Salinas RA, Castillo JL, Cea JG. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev 2008; :CD001552.
- Radwin RG, Sesto ME, Zachary SV. Functional tests to quantify recovery following carpal tunnel release. J Bone Joint Surg Am 2004; 86-A:2614.
- Naidu SH, Fisher J, Heistand M, Kothari MJ. Median nerve function in patients undergoing carpal tunnel release: pre- and post-op nerve conductions. Electromyogr Clin Neurophysiol 2003; 43:393.
- Jarvik JG, Comstock BA, Kliot M, et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial. Lancet 2009; 374:1074.
- Bland JD. Treatment of carpal tunnel syndrome. Muscle Nerve 2007; 36:167.
- Capasso M, Manzoli C, Uncini A. Management of extreme carpal tunnel syndrome: evidence from a long-term follow-up study. Muscle Nerve 2009; 40:86.
- Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions. Arch Phys Med Rehabil 2000; 81:424.
- Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev 2012; :CD010003.
- Manente G, Torrieri F, Di Blasio F, et al. An innovative hand brace for carpal tunnel syndrome: a randomized controlled trial. Muscle Nerve 2001; 24:1020.
- Premoselli S, Sioli P, Grossi A, Cerri C. Neutral wrist splinting in carpal tunnel syndrome: a 3- and 6-months clinical and neurophysiologic follow-up evaluation of night-only splint therapy. Eura Medicophys 2006; 42:121.
- Gerritsen AA, Korthals-de Bos IB, Laboyrie PM, et al. Splinting for carpal tunnel syndrome: prognostic indicators of success. J Neurol Neurosurg Psychiatry 2003; 74:1342.
- Graham RG, Hudson DA, Solomons M, Singer M. A prospective study to assess the outcome of steroid injections and wrist splinting for the treatment of carpal tunnel syndrome. Plast Reconstr Surg 2004; 113:550.
- Sevim S, Dogu O, Camdeviren H, et al. Long-term effectiveness of steroid injections and splinting in mild and moderate carpal tunnel syndrome. Neurol Sci 2004; 25:48.
- GARLAND H, LANGWORTH EP, TAVERNER D, CLARK JM. SURGICAL TREATMENT FOR THE CARPAL TUNNEL SYNDROME. Lancet 1964; 1:1129.
- Celiker R, Arslan S, Inanici F. Corticosteroid injection vs. nonsteroidal antiinflammatory drug and splinting in carpal tunnel syndrome. Am J Phys Med Rehabil 2002; 81:182.
- Gooch CL, Mitten DJ. Treatment of carpal tunnel syndrome: is there a role for local corticosteroid injection? Neurology 2005; 64:2006.
- Keir PJ, Rempel DM. Pathomechanics of peripheral nerve loading. Evidence in carpal tunnel syndrome. J Hand Ther 2005; 18:259.
- Freeland AE, Tucci MA, Barbieri RA, et al. Biochemical evaluation of serum and flexor tenosynovium in carpal tunnel syndrome. Microsurgery 2002; 22:378.
- Fuchs PC, Nathan PA, Myers LD. Synovial histology in carpal tunnel syndrome. J Hand Surg Am 1991; 16:753.
- Kerr CD, Sybert DR, Albarracin NS. An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: report of 625 cases. J Hand Surg Am 1992; 17:1028.
- Neal NC, McManners J, Stirling GA. Pathology of the flexor tendon sheath in the spontaneous carpal tunnel syndrome. J Hand Surg Br 1987; 12:229.
- Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev 2007; :CD001554.
- Atroshi I, Flondell M, Hofer M, Ranstam J. Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial. Ann Intern Med 2013; 159:309.
- Armstrong T, Devor W, Borschel L, Contreras R. Intracarpal steroid injection is safe and effective for short-term management of carpal tunnel syndrome. Muscle Nerve 2004; 29:82.
- Gottlieb NL, Riskin WG. Complications of local corticosteroid injections. JAMA 1980; 243:1547.
- Ly-Pen D, Andréu JL, de Blas G, et al. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum 2005; 52:612.
- Hui AC, Wong S, Leung CH, et al. A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology 2005; 64:2074.
- O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev 2003; :CD003219.
- Chang MH, Ger LP, Hsieh PF, Huang SY. A randomised clinical trial of oral steroids in the treatment of carpal tunnel syndrome: a long term follow up. J Neurol Neurosurg Psychiatry 2002; 73:710.
- Wong SM, Hui AC, Tang A, et al. Local vs systemic corticosteroids in the treatment of carpal tunnel syndrome. Neurology 2001; 56:1565.
- Herskovitz S, Berger AR, Lipton RB. Low-dose, short-term oral prednisone in the treatment of carpal tunnel syndrome. Neurology 1995; 45:1923.
- Garfinkel MS, Singhal A, Katz WA, et al. Yoga-based intervention for carpal tunnel syndrome: a randomized trial. JAMA 1998; 280:1601.
- Tal-Akabi A, Rushton A. An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome. Man Ther 2000; 5:214.
- Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev 2012; :CD009899.
- Nakamichi K, Tachibana S. Restricted motion of the median nerve in carpal tunnel syndrome. J Hand Surg Br 1995; 20:460.
- Greening J, Smart S, Leary R, et al. Reduced movement of median nerve in carpal tunnel during wrist flexion in patients with non-specific arm pain. Lancet 1999; 354:217.
- Valls-Solé J, Alvarez R, Nuñez M. Limited longitudinal sliding of the median nerve in patients with carpal tunnel syndrome. Muscle Nerve 1995; 18:761.
- Fernández-de-Las Peñas C, Ortega-Santiago R, de la Llave-Rincón AI, et al. Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. J Pain 2015; 16:1087.
- Michlovitz SL. Is there a role for ultrasound and electrical stimulation following injury to tendon and nerve? J Hand Ther 2005; 18:292.
- Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Therapeutic ultrasound for carpal tunnel syndrome. Cochrane Database Syst Rev 2013; :CD009601.
- Ebenbichler GR, Resch KL, Nicolakis P, et al. Ultrasound treatment for treating the carpal tunnel syndrome: randomised "sham" controlled trial. BMJ 1998; 316:731.
- Oztas O, Turan B, Bora I, Karakaya MK. Ultrasound therapy effect in carpal tunnel syndrome. Arch Phys Med Rehabil 1998; 79:1540.
- Chang MH, Chiang HT, Lee SS, et al. Oral drug of choice in carpal tunnel syndrome. Neurology 1998; 51:390.
- Carter R, Aspy CB, Mold J. The effectiveness of magnet therapy for treatment of wrist pain attributed to carpal tunnel syndrome. J Fam Pract 2002; 51:38.
- Weintraub MI, Cole SP. Neuromagnetic treatment of pain in refractory carpal tunnel syndrome: An electrophysiological and placebo analysis. J Back Musculoskelet Rehabil 2000; 15:77.
- Irvine J, Chong SL, Amirjani N, Chan KM. Double-blind randomized controlled trial of low-level laser therapy in carpal tunnel syndrome. Muscle Nerve 2004; 30:182.
- Evcik D, Kavuncu V, Cakir T, et al. Laser therapy in the treatment of carpal tunnel syndrome: a randomized controlled trial. Photomed Laser Surg 2007; 25:34.
- Barbosa RI, da Silva Rodrigues EK, Tamanini G, et al. Effectiveness of low-level laser therapy for patients with carpal tunnel syndrome: design of a randomized single-blinded controlled trial. BMC Musculoskelet Disord 2012; 13:248.
- Padua L, Padua R, Aprile I, et al. Multiperspective follow-up of untreated carpal tunnel syndrome: a multicenter study. Neurology 2001; 56:1459.
- APPROACH TO MANAGEMENT
- Initial therapy
- Failure of initial nonsurgical therapy
- Failure of surgical decompression
- SURGICAL DECOMPRESSION
- NONSURGICAL TREATMENT OPTIONS
- Wrist splinting
- - Splinting versus surgery
- Glucocorticoid injection
- - Glucocorticoid injection versus surgery
- Oral glucocorticoids
- Other nonsurgical options
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS