Carpal Tunnel Syndrome: Treatment Options

Carpal Tunnel Syndrome: Treatment Options

The treatment options for carpal tunnel syndrome may be nonsurgical or surgical. Nonsurgical treatment may be for patients with mild to moderate carpal tunnel syndrome. It is useful when there is no muscle weakness or atrophy, absent denervation or nerve supplies intact, and mild abnormality in nerve conduction studies.

Pregnant women with carpal tunnel syndrome rarely require surgery as symptoms resolve spontaneously. Nonsurgical treatment includes activity avoidance, use of a hand brace, splinting of the wrist, oral steroids, local injection of corticosteroids, nonsteroidal anti-inflammatory drugs, oral vitamin B6, ultrasound and laser therapy, workplace modifications, exercise, and yoga.

Out of these, steroid injection is the most successful treatment, though it may cause symptoms to worsen temporarily, but can produce complete or significant pain relief for 60% to 70% of patients for weeks to years.

Surgical treatment is reserved for patients with moderate to severe symptoms of carpal tunnel syndrome for whom conservative treatment has failed. These patients experience subjective weakness, clumsiness, severe numbness, thin arm muscle atrophy or muscle wasting, and severe loss of dexterity. A strong indication for carpal tunnel release is muscular atrophy or wasting.

The surgical procedure consists of releasing the transverse carpal ligament. This releases the pressure over the compressed median nerve and increases the space in the carpal tunnel. There are two different types of surgical approaches: open and endoscopic release.

Open carpal tunnel release is not to be confused with the mini-open technique described next. The procedure uses a 4 cm to 5 cm longitudinal incision, as seen here. This incision opens a substantial amount of tissue through the skin and underlying layers down to the transverse carpal ligament. Remember, this is the ligament that must be cut to relieve pressure from over the compressed median nerve.

The overall success of open carpal tunnel release ranges between 75% to 90%, while recurrence has been reported in 4% to 57% of the cases. There have been several modifications to the length, location, and shape of the incision in open carpal tunnel release. The most common modification is the mini-open release. This technique uses a 2 cm to 2.5 cm longitudinal incision to release the transverse carpal ligament under direct visualization. The view is actually somewhat limited for the surgeon during the surgery due to the smaller mini-incision.

Besides open techniques, there are several endoscopic approaches with the same underlying principle to release the transverse carpal ligament. There are less invasive techniques to facilitate earlier return to work for the patient with less pain and scarring. Endoscopic carpal tunnel release techniques can be divided into single-portal and two-portal techniques.

The two most commonly used techniques are the single-portal technique described by Dr. Agee in the early 90s and the two-portal technique described by Dr Chow in the late 80s, both still used today. The single-portal technique makes use of a small 1 cm transverse incision at the palmar crease to insert a device that transects the transverse carpal ligament by pulling back in a single motion.

The two-portal technique uses the same 1 cm palmar crease incision along with a midpalmar incision as well to gain access to the carpal canal. Several studies comparing endoscopic and open techniques found that endoscopic carpal tunnel release was associated with reduced scar tenderness and an increase in pinched grip and pinched strength by 12 weeks after surgery.