Doctors Finally Have a Uniform Plan to Treat Carpal Tunnel Syndrome

The American Association of Orthopaedic Surgeons (AAOS) put together a special committee to develop a clinical practice guideline on the treatment of carpal tunnel syndrome (CTS). The Guideline Workgroup worked together reviewing the most up-to-date evidence collected from clinicians and researchers to guide them.

Carpal tunnel syndrome is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

This syndrome has received a lot of attention in recent years. Many people thought it might be linked with occupations that require repeated use of the hands. The number of patients with CTS seemed to be increasing as more people were spending time typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

So, finding a way to treat CTS in all patients has become important. In the past, the AAOS published clinical practice guidelines for the diagnosis of CTS. Turning their focus to the treatment of this condition was the next step.

A work group was selected and the process began in December 2007. Once the review was completed, the process was opened to public comments. Several special committees reviewed the results before presenting the final recommendations to the AAOS Board of Directors in September 2008. There are nine basic recommendations. Here is a summary of the main points:

  • Once the diagnosis is made, conservative (nonoperative) care is advised first.
  • If conservative care does not improve the patient’s symptoms within two to seven weeks, then try a different nonoperative approach.
  • Splinting or steroids (oral or injections) are two treatment possibilities that have shown successful results. Heat should not be used to treat this problem.
  • Surgery is considered an option when electrodiagnostic tests show that the median nerve is damaged.
  • When surgery is done, the flexor retinaculum (band of connective tissue across the wrist over the carpal tunnel) should be completely cut all the way through. This is recommended no matter what surgical approach (open, mini-incision, endoscopic) is taken.
  • The use of several surgical techniques were not advised on a regular basis (e.g., skin nerve preservation, epineurotomy).
  • After carpal tunnel release, the wrist should not be immobilized in a splint or cast. Postoperative rehab may be helpful, but there isn’t enough evidence for or against this approach.

    These guidelines do not apply to patients who have CTS as a result of some other medical pathology. This would include patients with diabetes, thyroid problems, rheumatoid arthritis, or women with CTS who are pregnant. There isn’t enough evidence in the current research results to make specific treatment suggestions for these patients.

    Many types of nonoperative treatment are available. So far, there isn’t enough evidence for or against their use, so there isn’t a one-treatment-fits-all approach. Conservative care includes such things as acupuncture, electrical stimulation, nutritional supplements, yoga, or magnet therapy.

    There is a need to continue researching the effects of other treatments including stretching, laser, medications, therapeutic touch, vitamin B6, and stopping smoking. In time, studies may show subgroups of patients who benefit the most from a single treatment approach or even a combined treatment protocol.

    The complete guideline, a list of the group members, and supporting documents are available on-line at www.aaos.org/guidelines. Regardless of the treatment approach used, physicians and surgeons are encouraged to do some before and after measurements. There are some specific tools available (e.g., Boston Carpal Tunnel Questionnaire; Disabilities of the Arm, Shoulder, and Hand; SF-36 Short Form Health Survey) that can help assess responses to treatment. The results could be very helpful for research purposes.