Nine Specific Recommendations for the Treatment of Carpal Tunnel SyndromeThe average lifetime cost of carpal tunnel syndrome (CTS) is about $30,000. That's for an injured worker so it includes medical costs, lost wages for the worker, and the cost of lost productivity for the employer. That explains why effective treatment is important all the way around. Reducing those costs and improving worker health and productivity is a key goal.
Toward that end, the American Academy of Orthopaedic Surgeons has published a Clinical Practice Guideline (CPG) for physicians to use when planning treatment for patients with diagnosed carpal tunnel syndrome. The guideline has nine specific recommendations covering nonsurgical and surgical treatment. Efforts were made to address various topics studied including timing of surgery (early vs. late) and the use of local steroid injections, splinting, or ultrasound treatment.
The experts reviewed current studies published on this condition and tried to guide surgeons as to when surgery should be done and the best postoperative approach for optimal results. The recommendations are only guidelines at the present time because most of the evidence was inconclusive or from poorly designed studies.
The Board of Directors who issued this clinical practice guideline urged that research must continue. Better quality studies are needed. Specific topics for research include risk of carpal tunnel syndrome for specific job categories, best treatment options for patients who want to return to those jobs, and whether or not modifications in the workplace are worth the time and money. In other words, do they help prevent carpal tunnel syndrome?
These guidelines are for a specific subgroup of patients who have reversible carpal tunnel syndrome. They do not apply to patients with diabetes-induced CTS or other microscopic nerve damage from disease rather than compression. Most of the time conservative (nonsurgical) care is recommended first. But there are some patients who will be choose to go right to surgery rather than try the nonsurgical approach.
Quality of life is just as important as any other measure of outcome and should be included in the assessment. To get an idea of before and after treatment results, the authors suggest that physicians, surgeons, and researchers use one of several tools to test patient responses. Besides quality of life, other areas of change caused by the treatment can be function, pain, motion, and strength. The Boston Carpal Tunnel Questionnaire and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire are two good instruments used by many physicians for this purpose.
Now, as to the recommendations actually made by the Academy. Number 1: nonsurgical treatment is tried first. This can include local steroid injections, oral steroids, or physical therapy. The therapist may use ultrasound, splinting, nerve and tendon gliding exercises, and joint mobilization to help take pressure off the nerve. Surgery may be done early when it looks like the nerve is already damaged. The goal is to prevent irreversible nerve damage.
Number 2: If the selected treatment does not reduce or eliminate the symptoms after seven weeks, then another form of conservative (nonoperative) care should be tried. This could be any of the approaches already mentioned but not already tried. There is fair evidence that different patients benefit from a variety of nonsurgical approaches. It may be just a matter or trial and error to find the right mix for each patient.
Number 3: Evidence for the optimal approach in treating CTS caused by other medical conditions such as diabetes, pregnancy, or hypothyroidism is fairly limited. The authors could not give specific guidelines for this area.
Number 4: There is fair evidence that local steroid injection and splinting can help and should be tried before opting for surgery. These measures are more likely to benefit patients with mild to moderate carpal tunnel syndrome. Injections seem to work better than oral steroids (pill form). Severe symptoms or symptoms that have been present for a long time may not respond to this approach and will require more aggressive (surgical) treatment.
Number 5:When surgery is advised, the authors recommend cutting completely through the flexor retinaculum. This band of fascia or connective tissue crosses the wrist on the palm-side of the wrist/hand. Releasing the retinaculum takes pressure off the median nerve immediately. Various methods can be used to accomplish this (open incision, endoscopic approach, minimally invasive). It's not as clear which surgical technique gives the best results as the fact that whatever way it's done, the retinaculum release is a huge benefit.
Number 6: Certain procedures are not advised when performing surgery for carpal tunnel release. These include preserving the nerve to the skin and epineurotomy defined as surgical release of the epineurium. The epineurium is the outermost layer of connective tissue surrounding the nerve. It includes the blood vessels supplying the nerve.
Number 7: Surgeons may prescribe antibiotics for their patients before having carpal tunnel surgery. But studies to support or negate this idea have been inconclusive. The rate of infections after surgery may vary depending on the presence of other health problems such as diabetes. Usually studies exclude patients with other health issues. So, comparisons between patients with and without these comorbidities are not available.
Number 8: Immobilizing the wrist after surgery in a cast or splint isn't necessary. Evidence to support or negate rehab after surgery is missing. No recommendation could be made about postoperative rehab. Immobility can increase stiffness, prevent nerve and tendon gliding, and actually delay return-to-work.
Number 9: As already mentioned, it is important to compare before and after treatment to quantify any changes. That way, researchers can look back and see what treatments worked the best. There are many different questionnaires and patient self-report measures available to accomplish this. Only tests that have proven reliability and validity should be used. This report includes a table of 10 commonly used tools to assess patients and an idea of how reliable and responsive each one is. Tools of this type that are specifically designed and tested for with a problem like carpal tunnel syndrome have the greatest amount of responsiveness.
There are some treatments for which the Academy could not speak for or against. There simply wasn't enough evidence to make conclusions about activity modifications, acupuncture, cognitive behavioral therapy, cold laser, diuretics (water pills), or stretching exercises. Likewise, no recommendation could be made for or against such things as massage therapy, magnet therapy, nutritional supplements, therapeutic touch, or vitamin B6. Losing weight, quitting smoking, practicing yoga or other types of lifestyle changes have not been adequately studied either.
Despite the many, many studies already done on carpal tunnel syndrome, there is still a need for high-quality evidence-based studies to identify specific treatments (or combinations of treatment modalities) that are effective. The role of work hardening, work simulation, or some other program to prepare patients to return to their work setting has not been studied. This would be another good area to research.
Michael Warren Keith, MD, et al. AAOS Clinical Practice Guideline Summary. Treatment of Carpal Tunnel Syndrome. In Journal of the American Academy of Orthopaedic Surgeons. June 2009. Vol. 17. No. 6. Pp. 397-405.
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