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Carpal tunnel syndrome - Management
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What underlying contributory factors should I exclude?

  • Family history: one in four people with carpal tunnel syndrome have a positive family history in first degree relatives.
  • Inflammatory conditions: rheumatoid arthritis, gout, pseudogout, non-specific tenosynovitis of the flexor tendons, connective tissue disease (e.g. systemic lupus erythematosis).
  • Metabolic causes: hypothyroidism, diabetes mellitus, acromegaly.
  • Increased canal volume: congestive heart failure, oedema, pregnancy, obesity in younger people.
  • Fractures: Colles' fracture; fracture dislocation of the radiocarpal, carpal, and carpometacarpal joints.
  • Abnormal anatomy: ganglion, lipoma, haemangioma, neurofibromas, median artery aneurysm or arteriovenous malformation, xanthoma, congenitally small carpal canal.
  • Tumours: of the median nerve.
  • Amyloidosis: (e.g. secondary to renal failure).
  • Infections: Lyme disease, mycobacterial infection, septic arthritis.
  • Use of hand-held vibrating tools.
  • Do not routinely request laboratory tests to screen for underlying causes or contributory factors.
Basis for recommendation
  • The basis of these recommendations is expert advice in review articles [Viera, 2003; Barnardo, 2004; Bland, 2007] and the guidelines of the American Academy of Neurology [Quality Standards Subcommittee of the American Academy of Neurology, 1993].
  • There is evidence that the prevalence of diabetes mellitus, hypothyroidism, and rheumatoid arthritis is higher in people with carpal tunnel syndrome. A systematic review found insufficient evidence to recommend routine laboratory screening for concurrent disease in people with a new diagnosis of carpal tunnel syndrome [van Dijk et al, 2003].
  • There is believed to be a strong genetic disposition towards carpal tunnel syndrome. A study of monozygotic (n = 867) and dizygotic (n = 970) female twin pairs found that up to half the liability to develop carpal tunnel syndrome in women is genetically determined and this appeared to be the strongest risk factor [Hakim et al, 2002].

What treatment should I advise?

  • Treat any underlying cause.
  • Treat symptoms if they are interfering with quality of life. If the symptoms are mild or moderate and are not progressing:
    • Explain that the symptoms may resolve within 6 months. This is most likely to occur in young people (less than 30 years of age), if the symptoms are unilateral and of short duration, and in women in whom fluid retention due to pregnancy is the precipitating factor.
    • Advise wearing a wrist splint at night that maintains the wrist at a neutral angle without applying direct compression. Any improvement should be apparent within 8 weeks of use.
    • Advise minimization of activities that exacerbate symptoms. Explain to people who work with computer keyboards that there is little evidence to suggest that modifications at their work place are likely to be of any help in relieving symptoms.
    • Do not recommend the use of nonsteroidal anti-inflammatory drugs or diuretic medication.
Basis for recommendation
  • These recommendations are based on the guideline from the American Academy of Neurology [Quality Standards Subcommittee of the American Academy of Neurology, 1993].
  • If carpal tunnel syndrome arises from inflammatory arthritis (e.g. rheumatoid arthritis) then treatment of the underlying condition generally relieves the carpal tunnel symptoms [Katz and Simmons, 2002].
  • The purpose of treatment is to alleviate symptoms and, in some people, to prevent worsening of the condition. As carpal tunnel syndrome is not necessarily progressive there is nothing to be gained by treating people (mostly elderly) who have thenar wasting but no symptoms [Bland, 2007].
  • Evidence from observational studies shows that symptoms resolve spontaneously in some people: good prognostic indicators include short duration of symptoms, a young age, and carpal tunnel syndrome due to pregnancy.
  • Activity modification has no positive support from any randomized trials [Bland, 2007]. The benefit of modifying the person's activities remains uncertain [Katz and Simmons, 2002]. However the American Academy of neurology suggests modification of activities [Quality Standards Subcommittee of the American Academy of Neurology, 1993] and expert opinion in a review article suggested that it is reasonable to advise that people minimize any activities that exacerbate their symptoms [Katz and Simmons, 2002]. There is limited evidence that carpal tunnel mobilization and the use of workplace interventions (ergonomic adjustments) help people with carpal tunnel syndrome [Verhagen et al, 2006].
  • Treatment focuses on decompression of the median nerve in the canal.
    • There is good evidence that wrist splinting is effective in the short term in about 50% of people. In the long term, surgical treatment relieves symptoms of carpal tunnel syndrome more effectively than splinting. The neutral position of the splint decreases the potential for nerve stretching and therefore alleviates symptoms [Kanaan and Sawaya, 2001; Bland, 2007].
    • Although there is moderate evidence for the effectiveness of oral corticosteroids, adverse effects preclude their use [Bland, 2007].
    • There is limited or no evidence for short-term benefit from other non surgical treatments (e.g. ultrasound, yoga, vitamin B6).
    • There is no evidence to recommend the use of diuretics or nonsteroidal anti-inflammatory drugs.

When should I refer?

  • Referral may be to a rheumatologist, orthopaedic surgeon, hand surgeon, or neurologist depending on local custom and practice, and in some areas people may be referred to a Clinical Assessment and Treatment Service.
    • Offer referral for consideration of electromyography and nerve conduction studies if the diagnosis is uncertain and also before surgery.
    • Offer referral for consideration of corticosteroid injection or for surgical treatment if:
      • The symptoms are severe or constant, or there is severe sensory disturbance and/or thenar motor weakness.
      • There is progressive motor or sensory deficit.
      • There is no improvement within 3 months with conservative treatment.
Basis for recommendation
  • These recommendations are based on the guideline from the American Academy of Neurology [Quality Standards Subcommittee of the American Academy of Neurology, 1993] and expert opinion in a review article.
  • There is good evidence that local corticosteroid injection provides short-term improvement in symptoms. The risk of median nerve damage from intraneural injection is very small and has been estimated at < 0.1% in competent hands [Bland, 2007]. The major complication is direct injection of corticosteroid into the median nerve leading to severe axonal and myelin degeneration [Haase, 2007]. There is no evidence to support giving more than one injection [Marshall et al, 2007].
  • If compression is severe or there is insufficient improvement with conservative measures then surgery is the only treatment [Kanaan and Sawaya, 2001]. There is good evidence for the effectiveness of surgical treatment by open or endoscopic carpal tunnel release. Most clinicians recommend that if people have not benefited from conservative treatment then they should be considered for surgery.
  • Electrodiagnostic testing is recommended if the diagnosis is in doubt [Quality Standards Subcommittee of the American Academy of Neurology, 1993].
  • Under the government's proposals outlined in The musculoskeletal framework, future referrals may be dealt with increasingly by the local Clinical Assessment and Treatment Service (CATS). The report gives one example where joint working supported one GP practice to undertake carpal tunnel decompression surgery in primary care [DH, 2006].

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