Treatment

Patient management is based on severity of CTS symptoms and degree of injury as found on electrodiagnostic studies.

Grading Severity of CTS (Kothari, 2022c)
Clinical Grading	Signs and Symptoms
Mild	Numbness, tingling, or discomfort in the median nerve. No sensory loss or weakness, no sleep disruption, no difficulty with hand function or interference with activities of daily living (ADLs).
Moderate	Sensory loss in the median distribution or symptoms at night that disrupt sleep. Symptoms may interfere slightly with hand function, but the patient is able to perform all ADLs.
Severe	Weakness in the median distribution or if symptoms are disabling and prevent the patient from one or two ADLs, or if nocturnal symptoms routinely disrupt sleep.

Nonsurgical Management (Kothari, 2022c)

Nonsurgical treatment should be implemented first-line for patients with mild CTS who haven’t had electrodiagnostic studies. A combination of therapies (splinting along with glucocorticoid injections, oral glucocorticoids, or other nonsurgical interventions) may be more effective than any single treatment. Improvement may take up to 6 months.

• Lifestyle modifications
  • Avoid repetitive motions
  • Take frequent breaks
  • Use ergonomic equipment
  • Alternate job functions
• Wrist splinting
  • Recommend a neutral-positioned wrist orthosis worn at night for short-term symptom relief and functional improvement for nonsurgical management (Erickson et al., 2019)
  • Wrist splinting in neutral position and 0° extension with custom-fit wrist splints for night-time use and as needed for daytime symptoms
  • Minimum of 6 to 8 weeks; if symptoms persist after one month, continue splinting for another 1 to 2 months and add another therapy (oral or injection corticosteroid)
• Corticosteroid injections – should be the next option (before oral corticosteroids) if splinting is unsuccessful
  • Reduces tissue inflammation
  • May provide relief for up to a year
  • Single injection of methylprednisolone, with 40 mg as the recommended dose
  • Contraindicated with Thenar muscle weakness and/or atrophy or advanced sensory loss
  • Multiple injections are not recommended; limit frequency of injections for CTS to no more than once every six months per wrist; for recurrent symptoms after two injections, consider other nonsurgical treatments or surgical evaluation
  • Risks include worsening of median nerve compression, accidental injection into the median or ulnar nerve, and digital flexor tendon rupture
• Oral corticosteroids
  • Provide short-term relief
  • Use in patients who decline injection therapy
  • Prednisone 20 mg daily for 10 to 14 days 
  • Do not use for more than 4 weeks due to adverse effects
• Exercises
  • Refer to physical and occupational therapists with certification in hand therapy
    • Nerve and tendon gliding – may restore normal movement of the median nerve
    • Carpal bone mobilization – movement of the bones and joints in the wrist
• Ultrasound therapy and electrical stimulation
  • Ultrasound promotes soft tissue healing and transdermal absorption of medications; however, evidence is limited
  • Deep, pulsed ultrasound may decrease pain and improve sensory loss, nerve conduction, and strength
  • Effectiveness may depend on duration of therapy
• Ineffective therapies: nonsteroidal anti-inflammatory drugs (NSAIDs), diuretics, vitamin B6, perineural dextrose injections, and electrical, magnetic, and laser therapy have not proven beneficial for the treatment of CTS.

Surgical Management (Kothari, 2022c)

• Surgical Decompression
  • When electrodiagnostic tests show severe and ongoing median nerve injury, surgical decompression is recommended, unless the cause is temporary such as pregnancy.
  • Surgical release of the transverse carpal ligament is typically performed.
  • Studies support there is a greater treatment benefit of surgery over nonsurgical treatment at 6 and 12 months.
  • Performed in outpatient setting under local anesthesia by a specialist
  • Prophylactic antibiotics given prior to carpal tunnel release are not recommended as there is no evidence of a reduction in postoperative surgical site infections.
  • Studies support there is no benefit to routine postoperative immobilization following carpal tunnel release.