Neurol Sci (2010) 31:243252

DOI 10.1007/s10072-009-0213-9

REVIEW ARTICLE

Diagnosis, treatment and follow-up of the carpal tunnel syndrome:

a review
Calogero Alfonso Stefano Jann Roberto Massa
Aldo Torreggiani

Received: 5 August 2009 / Accepted: 24 December 2009 / Published online: 10 February 2010
 Springer-Verlag 2010

Abstract The carpal tunnel syndrome is a compressive

neuropathy with high incidence rates, and its correct
diagnosis, treatment and follow-up may lead to significant
benefits in healthcare, social and economic terms. In this
review, based on systematic review databases and guidelines, we summarise the appropriate indications for the
diagnosis, treatment and follow-up, accompanied, whenever possible, by the levels of evidence and strength of
recommendations.
Keywords Carpal tunnel syndrome
Guidelines

Surgical therapy
Non-surgical therapy

Katz hand diagram

C. Alfonso
U.O. Ortopedia e Traumatologia, Azienda Ospedaliera di
Bologna Policlinico S. Orsola-Malpighi, Via Albertoni,
15, 40141 Bologna, Italy
e-mail: rinoalfonso@yahoo.it
S. Jann
U.O. Neurologia, A.O. Ospedale Maggiore Niguarda,
Piazza Ospedale Maggiore 3, 20162 Milan, Italy
e-mail: Stefano.Jann@OspedaleNiguarda.it
R. Massa
Dipartimento di Neuroscienze Universita` di Roma
Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
e-mail: massa@uniroma2.it
A. Torreggiani (&)
Via Ciovasso, 4, 20121 Milan, Italy
e-mail: torex@tin.it

Introduction
The present article, first in a series of two, is meant to
suggest a synthesis of the current knowledge that could
lead to the definition of diagnostic and therapeutic procedures aimed at improving the quality of care for
patients affected by the most-frequent compressive
neuropathies: carpal tunnel syndrome and lumbar sciatic
pain.
For the preparation of this paper, we consulted several
sources capable of providing a reliable and authoritative
synthesis of the current knowledge of specific aspects of
each disease: the Cochrane Library (database created by
the Cochrane Collaboration including, among other
things, systematic literature reviews) [1], clinical evidence (a summary of evidences, organised by disease,
that reports information on incidence and prevalence,
therapeutic and diagnostic, clinical and instrumental
aspects, as well as prognostic features) [2], and
guidelines.
Reference to the guidelines on the selected topics is
always indicated by the authors with the corresponding
strength of recommendations and level of evidence [3].
The LOE acronym represents the classification according to the Levels of Evidence, identified by Roman
numerals. By LOE, we refer to the probability that a given
number of evidence be derived from studies planned and
conducted in such a way as to produce valuable information, free from systematic errors.
The SOR acronym designates the Strength of Recommendations. These are indicated by letters from A to E.
By SOR, we refer to the probability that the clinical
application of a recommendation determine an improvement in the health condition of the population to whom the
recommendations are directed Tables 1, 2.

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Table 1 Levels of evidence [3]

I

Evidence obtained from several randomised controlled clinical

trials and/or from systematic reviews of randomised studies

II

Evidence obtained from a single randomised trial with adequate

design

III Evidence obtained from cohort studies with concurrent or

historical controls or from their meta-analysis
IV Evidence obtained from retrospective casecontrol studies or
from their meta-analysis
V

Evidence obtained from case studies (case series) without control

group

VI Evidence based on the opinion of authoritative experts or expert

committees as indicated in guidelines or consensus conferences,
or based on opinions of the members of the working group

neuropathies, pain is caused by an abnormal diffusion of

the Na? channels into the damaged nociceptive fibres,
with hyperexcitability and ectopic discharge induction.
An important role in the genesis of compressive neuropathic pain is played by inflammatory mediators, in
particular TNFa [4].
Compressive radiculo-neuropathies are frequent disorders (represent a series of diffuse diseases) with similar
(invariable) pathogenesis, and they correspond to a high
percentage of general practitioners and specialists outpatient activities, and of pharmaceutical, hospitalisation
and rehabilitative expenses. Carpal tunnel syndromes and
lumbar disc herniations are the most-relevant clinical
manifestations.

The carpal tunnel syndrome

Table 2 Strength of Recommendations [3]
A Performance of a given procedure or diagnostic test is highly
recommended. Indicates a particular recommendation supported
by scientific evidence of a good level, although not necessarily
of levels I or II
B Questions arise on the fact that a given procedure/intervention
should always be recommended, and its performance must
always be carefully taken into consideration
C Considerable uncertainty exists in favour or against the
recommendation to perform a procedure or intervention
D Performance of the procedure is not recommended
E It is strongly recommended not to perform the procedure

Compressive and entrapment neuropathies

Compressive neuropathies are mononeuropathies or radiculopathies caused by mechanical distortion produced by a
compressive force. In particular, we define entrapment
neuropathy a chronic focal compressive neuropathy caused
by a pressure increase inside specific unstretchable anatomical structures (channels) [4].
When the nerve fibres are subjected to a mechanical
force, demyelination of the paranodal region initially
develops in the compression site, which then spreads to
the entire internodal segment. In this first phase, a block
of nervous transmission occurs, caused by focal demyelination with intact axons (neuroapraxia). If the compression persists, blood flow to the endoneural capillary
system may be interrupted, leading to alterations in the
blood-nerve barrier, development of endoneural oedema,
and onset of a vicious circle made of venous congestion,
ischaemia and local metabolic alterations. This series of
events, if protracted in time, may lead to axonal
degeneration, macrophage attraction and activation,
release of inflammatory cytokines, nitric oxide, and
development of chemical neuritis [4]. In compressive

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The carpal tunnel syndrome (CTS) is a neuropathy caused

by entrapment of the median nerve at the level of the carpal
channel, delimitated by the carpal bones and by the
transverse carpal ligament.
Epidemiology
CTS is the most-frequent entrapment neuropathy, with
prevalence rates of up to 9.2% in women and 6% in men
[5] and incidence rates of up to 276:100,000/year [6].
Considering the data of the 2001 Second Dutch Survey
of General Practice, concerning a population of almost
400 thousand subjects, a 6.5% yearly incidence of upper
limb disorders was estimated, higher in women (7.6%)
than in men (5.6%), with a 15% prevalence (12% in men
and 17% in women) [7]. In all Western countries, an
increase is reported in the number of work-related
musculoskeletal disorders (WMSDs) caused by strain and
repeated movements (biomechanical overload). In Europe, in 1998, over 60% of upper limb musculoskeletal
disorders recognised as work-related were CTS cases [8,
9]. Data reported by INAIL (the Italian National Institute
for Insurance against Industrial Accidents) concerning
WMSDs in the period 19962000 show a marked
increase both in the reported cases, and in the recognised
ones: from the 931 reported and 10 accepted cases in
1996, they reached 1960 reported and 1,061 accepted
cases in 2000. The most-frequent disorders reported in
2000 were CTS (57%), wrist, hand and shoulder tendinitis (19%), epicondylitis (10%), and disc arthrosis and
herniation (7%) [10]. In 2000, of the WMSDs accepted
by INAIL, 39% derived from the engineering sector,
11% from the textile and clothing industry, 9.5% from
the food sector, 4.6% from the ceramic industry, 4%
from the building industry, 2.4% from wood processing,

Neurol Sci (2010) 31:243252

2.2% from the footwear sector, and 2% from the transport sector [11].
The number of WMSDs reported to INAIL has become
the highest, after the cases of hypoacusia, of the nonlisted professional diseases. In 2004, reports of CTS alone
were 941 [11]. Naturally, these data reflect the increasing
level of sensitivity to this problem, which is translated into
a higher number of reports, rather than reflecting an actual
increase.
Clinical features and stages
CTS may be classified on the basis of symptoms and signs
into three stages:
First stage:

Second stage:

Third stage:

Patients have frequent awakenings during

the night with a sensation of swollen,
numb hand; furthermore, they report of
severe pain that irradiates from the wrist
to the shoulder, and an annoying tingling
in their hand and fingers (brachialgia
paraesthetica nocturna). Hand shaking
brings relief. At morning, a sensation of
hand stiffness usually persists.
Presence of symptoms also during the day,
mostly when the patient remains in the
same position for a long time, or performs
repeated movements with hand and wrist.
When motor deficit appears, the patient
reports that objects often fall from his/her
hands.
Final stage, hypo-/atrophy of the thenar
eminence. In this phase, sensory
symptoms may diminish [12].

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manoeuvres which alleviate symptoms (hand shaking,

position changes), presence of predisposing (prognostic
no!) factors (diabetes, adiposity, chronic polyarthritis,
myxoedema, acromegaly, pregnancy), sports activity
(baseball, body-building) (Table 3).
Physical examination
The list of findings and manoeuvres used in the diagnosis
of CTS is long; however, a recent literature review has
focussed its attention on a symptom diagram, and on two
signs that are most of help in predicting a positive
electrodiagnosis of CTS (diagnostic test of reference)
[15].
The Katz hand diagram [16] is a self-administered diagram that allows the patient to localise symptoms and to
describe them as numbness, pain, tingling and
hypoesthesia.
The diagrams may be classified into three patterns.
Classical pattern:

Probable/possible pattern:

Symptoms affect at least two

of either first, second or third
fingers. Symptoms involving
the fourth and fifth fingers,
wrist pain and radiation of
pain proximal to the wrist are
permitted. Involvement of
palm or dorsum of the hand
is not allowed;
Same symptoms as in the
classical pattern, except for
the palmar symptoms, which
are accepted if limited to the
median side. Possible pattern:
involvement of only one of

Diagnosis
The clinical pattern is well known, and two papers by the
Quality Subcommittee of the American Academy of Neurology (AAN) defined the guidelines for clinical [10] and
neurophysiologic diagnosis [11].
Two papers by the Quality Standards Subcommittee of
the American Academy of Neurology [13] and American
Association of Electrodiagnostic Medicine, American
Academy of Neurology and American Academy of Physical Medicine and Rehabilitation defined the guidelines for
clinical and neurophysiologic diagnosis of CTS [14].
Case history must focus on symptom onset (in the early
stage, mainly nocturnal paraesthesias), provocative factors
(positions, repeated movements), working activity (instrument use, vibrating tools), pain localisation and irradiation
(in the cutaneous median nerve region with ascending,
sometimes up to the shoulder, or descending irradiation),

Table 3 The likelihood of CTS increases with the number of

symptoms and provocative or mitigating factors listed below [13]
Symptoms
Dull, aching discomfort in the hand, forearm, or upper arm
Hand paraesthesias
Weakness or clumsiness in the hand
Dry skin, swelling or colour changes of the hand
Occurrence of these symptoms in the median distribution
Provocative factors
Sleep
Sustained arm or hand positions
Repetitive actions of the hand and wrist
Mitigating factors
Change in hand posture
Shaking of the hand

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Unlikely pattern:

the first, second or third

finger;
No symptoms are present in
first, second or third finger.

A classical or probable diagram is indicative of CTS

(sensitivity = 0.64; specificity = 0.73; LR = 2.4; 95%
CI = 1.63.5) (LOE I) [15].
The finding of hypalgesia in the median nerve territory
(sensitivity = 0.51; specificity = 0.85; LR = 3.4; 95%
CI = 2.0-5.8) and weakness of the abductor pollicis brevis
muscle (sensitivity = 0.66; specificity = 0.66; LR = 2.0;
95% CI = 1.42.7) are indicative of CTS (LOE I) [15].
Some traditional manoeuvres such as the Tinel and
Phalen signs, the finding of a reduced two-point discrimination or of atrophy of the thenar eminence, has scarce or
no diagnostic value (LOE I, SOR D) [15]. It must be
remembered that objective examination may be absolutely
normal in patients with a typical case history of CTS [13]
(Table 4).
Differential diagnosis
CTS must be differentiated from:

Cervical radiculopathy (especially C6C7)

Brachial plexopathy (in particular of the upper trunk)
Proximal median neuropathy (especially at the pronator
teres level)
Thoracic outlet syndrome
CNS disorders (multiple sclerosis, small cerebral
infarction)

Instrumental diagnosis and its evaluation

Neurophysiological diagnosis
Nerve conduction studies and electromyography may
confirm, but not rule out, the diagnosis of CTS. The aims of
Table 4 Key points
Diagnosis
Clinical classification
First stage: brachialgia paraesthetica nocturna
Second stage: daytime complaints

this evaluation are the following: (1) to confirm a focal

damage to the median nerve inside the carpal tunnel; (2) to
quantify the neurophysiological severity by using a scale;
(3) to define the nerve pathophysiology: conduction block,
demyelination and axonal degeneration. In a recent review,
the American Association of Electrodiagnostic Medicine,
the American Academy of Neurology and the American
Academy of Physical Medicine and Rehabilitation defined
the Practice Parameters for electrodiagnostic studies in
CTS [14].
Electroneurography Median sensory and motor conduction studies have a mean overall sensitivity of 85% and
specificity of 95%. The standard examination involves a
measurement of the median nerve sensory conduction
velocity (SCV) across the wrist with a conduction distance
of in a 1314 cm (SORA). If this is altered, SCV is also
measured on a similar distance on another adjacent nerve in
the same hand (e.g., third finger-median vs. fifth fingerulnar) to rule out possible polyneuropathy. If SCV in the
median nerve is normal, one of the following additional
studies are recommended: (a) comparison of SCV or mixed
nerve CV through the wrist, over a 78 cm distance, with
ulnar SCV or mixed CV over the same distance, or: (b)
comparison of median SCV with SCV of another nerve in
the same finger (fourth median/ulnar finger or first median/
radial finger) or; (c) comparison of median SCV or mixed
CV through the carpal tunnel with proximal (forearm) or
distal (finger) median SCV or mixed CV (SOR A). The
study of motor conduction velocity and of distal motor
latency (DML) in the median and ulnar nerves in the same
hand may provide additional data (SOR B) [14].
Needle electromyography May be useful to confirm
axonal degeneration of the motor fibres innervating the
abductor pollicis brevis and opponens pollicis muscles. The
study of other upper limb muscles with C5-T1 innervation
may be useful in the differential diagnosis with disorders
more proximal to the median, or to rule out a radiculopathy
(SOR C) [14].
Neurophysiological classification In order to standardise
the diagnostic and therapeutic approach to any disease it is
essential to:
1.
2.

have a common interdisciplinary language,

have a classification possibly based on objective
findings, not on reported symptoms or on imprecise
and non-specific clinical signs.

Third stage: hypo-/atrophy of thenar eminence

An accurate case history leads to a first diagnostic hypothesis
A classical or probable Katz hand diagram is indicative of CTS
(SOR A)
Signs indicative of CTS (SOR A)
Hypalgesia in the median nerve territory
Weakness of the abductor pollicis brevis

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The electrophysiological classification [17, 18], in

agreement with the AAEM guidelines, follows the neurophysiological progression of CTS severity and includes the
following classes:
Negative CTS:

Normal findings on all tests (including

comparative and segmental studies);

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Minimal CTS:
Mild CTS:
Moderate CTS:
Severe CTS:
Extreme CTS:

Abnormal findings only on comparative

or segmental tests;
SCV slowed in the fingerwrist tract
with normal DML;
SCV slowed in the fingerwrist tract
with increased DML;
Absence of sensory response in the
fingerwrist tract with increased DML;
Absence of thenar motor response

This classification has the advantage/disadvantage of

using adjectives commonly used; therefore, we suggest to
specify that the quantification refers to neurophysiological
data (Table 5).
Diagnostic imaging
In most CTS cases, the cause is not easily identified (idiopathic form). The causes of the secondary forms of this syndrome include space-occupying lesions (tumours, synovial
tissue hypertrophy, bone formation, osteophytes), metabolic
and physiologic conditions (pregnancy, hypothyroidism,
rheumatoid arthritis), infections, neuropathies (associated to
diabetes mellitus or alcoholism), and familial disorders.
When the presence of space-occupying lesions is suspected, a wrist study performed by magnetic resonance or
by other imaging techniques (CT, X-ray) are of basic
importance for an aetiologic diagnosis. On other hand,
diagnostic imaging is not currently used in clinical practice
for the diagnosis of idiopathic CTS (SOR D). However,
MRI provides an excellent visualisation of the median
nerve and of its links with the other carpal tunnel structures
and, in particular, it allows for the individuation of either
nerve adhesion or compression. Last, a correlation between
some MRI parameters and the level of electrophysiologic
severity has recently been demonstrated [19, 20].
Treatment of the carpal tunnel syndrome
The conservative or surgical treatment of CTS is indicated
when symptoms are so painful as to interfere with daily
activities (SOR A) [13].

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The conservative treatment is suggested as a first option,

unless progressive motor deficit, severe sensory deficit or
serious electrophysiologic abnormalities occur [13]. The
most-frequent conservative treatments include:
1.
2.
3.
4.

Pharmacological treatment
There is an extremely limited number of studies on the
pharmacological treatment. First of all, it is important to
treat all conditions associated with CTS. In particular, the
treatment of rheumatoid arthritis or of other types of
inflammatory arthritis may improve symptoms. Hypothyroidism and diabetes mellitus must also be treated,
even though the effect of this treatment on CTS is still
uncertain.
The conservative treatment is generally more effective if
the neuroperipheral damage of peripheral nerve is mild
(intermittent hypoesthesia and absence of sensory or motor
deficit at neurological examination).
The most-common conservative treatments for CTS are:
steroids, both by systemic administration and by localinjection, non-steroidal anti-inflammatory drugs (NSAIDs),
diuretics, pyridoxine, and splinting.
Steroids The hypothesis is that they reduce interstitial
fluid pressure inside the carpal channel. Studies have been
conducted to assess the effect of oral prednisone administration, of the local administration of depot steroids, a
comparison study between the two ways of administration,
and one comparison study between intramuscular and
local-injection.
What emerges from these studies and is also underlined
by Cochrane reviews [22, 23] is that:

Table 5 Key points

Instrumental diagnosis
EMG and nerve conduction studies may confirm, but not rule out,
the diagnosis of CTS
Standard exam: measurement of sensory conduction velocity of the
median nerve in the third fingerwrist tract
It is essential to have an objective classification to evaluate the
electrophysiological severity of CTS
Diagnostic imaging is not used in clinical practice in the diagnosis
of idiopathic CTS

Modification of daily activities

Drugs (NSAIDs, oral or intracarpal steroid injections,
diuretics)
Ultrasonography
Hand and wrist splinting

Oral treatment with 25 mg prednisone/day for 10

consecutive days determines an improvement in symptoms for at least 8 weeks (LOE II).
The local administration of steroids is effective at least
in the short-term (24 weeks) (LOE I). Local administration is more effective than the intramuscular (LOE
II).
Local administration seems to be more effective than
the oral, at least in the short-term (LOE II).

Diuretics and NSAIDs In spite of their constant use,

these drugs have shown no effective results on controlled
studies (LOE I) [24]. In fact, CTS is not an inflammatory condition, and the pain it produces is not
neuropathic.

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Pyridoxine (vit. B6) Its administration has not proved to

be effective in controlled studies, in spite of the promising
initial data (LOE I) [26].
L-Acetyl-carnitine (LAC) Has been shown to have
analgesic effects in a series of 109 patients affected by CTS
(LOE V). As indicated in the case of lumbar sciatic pain,
the possibility that LAC have both a symptomatic and a
neuroprotective effect on pain, makes this treatment
promising [25] (Table 6).
Non-pharmacological treatment
The current evidence shows a significant short-term
improvement after wrist splinting and immobilisation.
Controversy also exists on the effectiveness of ultrasound
therapy. Other conservative treatments do not seem to
produce any improvements. Further studies are needed to
compare treatments and evaluate the duration of their
effectiveness over time.
Ultrasound treatment
In the literature, two randomised controlled studies are
reported. In the first study, the application of ultrasounds
(1.0 W/cm2, 15 min/session, 5 sessions/week for 5 weeks)
led to a significant improvement in pain, paraesthesias, and
hypoesthesia after 2 weeks, 7 weeks, and 8 months as
compared to placebo (0 W/cm2) (LOE II) [27].
The second study (of lower quality) compared the
effects of low-intensity (0.8 W/cm2) with high-intensity
(1.5 W/cm2) ultrasounds and placebo; no significant difference was evidenced in the severity of symptoms and in
the frequency of awakening at night in the three groups
after 20 days of treatment [28].
Hand and wrist splinting
Splinting has been used for over 40 years in the treatment
of CTS; however, randomised studies conducted on its
effectiveness are very few. One randomised controlled
study has proved that night-time wear of an innovative soft
hand brace for 4 weeks was associated to a significant

Neurol Sci (2010) 31:243252

improvement in symptoms and functions as measured with

the Boston Carpal Tunnel Symptom Questionnaire [29],
compared to the non-treated group (BCTS SYMPT: 1.21
vs. 0.16, P \ 0.001; BCTS FUNCT:0.41 vs. 0.01,
P \ 0.001) (LOE II) [30]. The degree of symptom and
function improvement was comparable to that reported in a
prospective study of patients after 3 months from surgical
intervention [28].
Another study compared the effectiveness of splints
immobilising the wrist at 20 extension with neutral
angle splints [31]. The results showed that after 2 weeks,
the neutral angle provided superior symptom relief as
compared to extension. However, a re-analysis of the
same data that simplified the outcome categories as
improvement and no improvement indicated that
there was no difference between the two types of splint
[31].
A third study did not evidence any significant difference
between the full-time or night-only wear of a neutral angle
splint used for 6 weeks [33].
Last, a small randomised study did not evidence any
significant difference between the association between
nerve and tendon gliding exercises (aimed at restoring the
maximum excursion of the median nerve and of the carpal
tunnel tendons) and the use of wrist splints as compared to
splinting alone in terms of symptoms or function
improvement after 8 weeks from the end of treatment [34].
MLS laser therapy
Multiwave locked system (MLS) laser therapy [3538] is
the synchronised delivery of continuous and pulsed laser
emissions with different infrared wavelengths. Thanks to
these features, it has an anti-oedema effect, as it stimulates
blood and lymphatic circulation and induces fast reabsorption of fluid build-ups. The components MLS laser
have been demonstrated to accelerate and improve the
quality of nerve regeneration in rats after lateral neurorraphy of the ulnar and median nerves. In vivo studies
demonstrated a complete remyelination at the level of the
median nerve, with recovery of nerve conduction and of
the contraction capacity of the innervated muscle, which
regains its capacity of correctly receiving the nervous
stimulation (Table 7).

Table 6 Key points

Pharmacological treatment

Surgical treatment

Conservative treatment is effective in the mild-moderate forms

Conservative treatment is suggested as a first option unless
progressive motor deficit, severe sensory deficit or serious
electrophysologic anomalies occur (SOR B)
Steroids are effective, mostly when administered locally
L-Acetyl-carnitine

combines a potentially neuroprotective effect

with effective pain control (LOE V)

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Several studies have been published on the indications and

effects of CTS treatments, including one guideline document [13].
Surgical indication is limited to patients in whom the
conservative treatment has not been effective in relieving
pain or with progressive motor deficit, severe sensory

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Table 7 Key points

Non-pharmacological treatment
The use of ultrasounds is controversial (SOR C)

2.

Questions remain on whether neutral angle wrist splinting is better

than extension splinting
A soft hand brace have a short-term effectiveness on symptoms and
functionality (SOR A)
Full-time splint wear does not lead to greater improvement as
compared to night-only wear

deficit or severe anomalies on electrodiagnostic examination (SOR B) [13].

No randomised controlled studies have ever been
reported in the literature comparing surgical versus no
treatment. In a recent review of 209 studies on the treatment of CTS published between 2000 and 2006, which
regarded 32,936 interventions, 75% of patients reported of
complete symptom resolution or of mild residual symptoms after intervention, 17% reported mild improvement or
no change, and 8% reported worsening [21].
There are three randomised controlled studies that
compare surgical versus conservative treatment [4042],
two of which were included in a systematic Cochrane
review [43]. In the studies included in the review [40, 42],
the non-surgical group had been treated by handwrist
forearm splinting for 4 or 6 weeks. In the more-numerous,
better-quality study, 71% of surgically treated patients
experienced significant improvement after 3 months as
compared to a 1.38 improvement (95% CI: 1.081.75) in
favour of surgery [40]. This improvement still persisted
after 6 and 18 months. In any case, it must be underlined
that in this study, after 18 months 41% of patients in the
splinting group had undergone surgical treatment. The
reviewers concluded that, although short-term (1 month)
statistical data were only mildly significant, surgical
treatment is more effective than conservative therapies in
preserving mid- to long-term improvement [43]. In the
study by Ly-pen et al. [41], the non-surgical group
underwent steroid treatment by local infiltration. Surgical
treatment was significantly less effective in improving
symptoms after 3 months (percentage of subjects with
improvement equal to or higher than 20%; nocturne paraesthesia: 94% with corticosteroids vs. 75% after surgery;
daytime pain: 89 vs. 69%; compromised function: 88 vs.
68%). However, after 6 and 12 month there were no significant differences between the two groups.
There are two surgical procedures:
1.

Open carpal tunnel release (OCTR) after curvilinear

skin incision in the palm, which may be associated, in
case of thickening of the external nerve sheath, to
epineurotomy and, if cicatricial tissue is present within

the nerve, to internal neurolysis to decompress the

single nerve fascicles.
Endoscopic carpal tunnel release (ECTR), characterised by sectioning of the ligament from inside the
carpal tunnel, leaving the structures and skin plane
above the tunnel intact.

Two systematic reviews [44, 45] and two randomised

studies [46, 47] are available, which compare the two
procedures. The conclusion is that, at the moment, there is
no evidence to support the superiority of ECTR over
OCTR in providing short- and long-term symptom
improvement and in leading to recovery of normal activities (LOE I, SOR A). At present, the decision on the
technique to be used seems to be basically linked to the
patients and surgeons preference.
Contraindications to surgical intervention
There are no specific contraindications to OCTR. The
patients clinical condition must be stable before the
intervention. Pregnant women should postpone the intervention because symptoms often disappear after delivery.
In contrast, ECTR is contraindicated [48]:
1.
2.

3.

4.
5.

6.

7.

8.

In case of rheumatoid arthritis (the intervention may

worsen the inflammatory process)
In CTS secondary to recent trauma with symptoms
suggesting the involvement of the median nerve,
limited wrist extension and previous wrist intervention
In case of recurrent tenosynovitis or other palmar
inflammations (these patients may benefit from neurolysis, which is only performed during OCTR)
In case of Dupuytren syndrome or in case of previous
hand interventions
In patients undergoing anticoagulant treatment,
because with ECTR only compressive haemostasis
may be achieved
When there is a marked involvement of the thenar
motor branch, which makes open exploration
necessary
When the patient prefers to undergo general anaesthesia, which does not allow for the patient to report
symptoms indicative of possible nerve lesions during
the procedure
In case of evident malformations or in the presence of
a mass.

Complications associated with the interventional technique

The frequency of complications varies from study to study,
independently of the technique. Two literature reviews
conclude that transient nerve disorders (neuroapraxia,

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Table 8 Key points

Table 9 Key points

Surgical treatment

Follow-up

Surgical indication is limited to patients in whom the conservative

treatment has not been effective in relieving pain or with
progressive motor deficit (SOR B)
Surgical treatment is more effective than conservative therapies in
preserving mid- to long-term improvement (SOR A)
After surgery, 75% of patients have complete symptom resolution,
8% worsen
At present, there is no evidence to support the superiority of ECTR
over OCTR (SOR A)
There are no specific contraindications to OCTR
There are several contraindications to ECTR
Postoperative use of rigid splints is probably useless or detrimental
(SOR D)

numbness and paraesthesia) are more frequent after ECTR,

while OCTR is more often the cause of complications
involving the wound (infection, hypertrophy and scar pain)
[44, 45].
Postoperative treatment
Keeping the hand lifted after the intervention and gradually
resuming hand functions are recommended (LOE VI) [13].
The use of rigid braces that immobilise the wrist for 2
3 weeks after the intervention is usually suggested [13],
although two randomised studies did not evidence any
significant difference in grip strength or in the number of
patients who were considered as healed after 24 weeks
[49, 50]. Another randomised study concludes that, compared to no treatment, the use of a splint for 2 weeks after
the intervention significantly delayed the return to work
[51] (Table 8).
Outcome evaluation and follow-up
For both conditions, both lumbosacral radiculopathy and
carpal tunnel syndrome, it is fundamental to individuate the
main outcome measures [52].
For lumbosacral radiculopathy, patient-centred outcome
measures may be used:

Clinical improvement according to the patient, general

practitioner, or both
Pain decrease
Improved quality of life
Return to work
Objective improvement at neurological examination
(reflexes, strength, sensitivity)
Possible surgical intervention

As concerns the carpal tunnel syndrome, the Global

Symptom Score (GSS) is often used. It consists in the

123

For CTS outcome evaluation, the Generic Summary Score (GSS) is

used

numerical quantification from 0 (no symptom) to 10 (worst

possible symptom) of 5 symptoms: pain, paraesthesia,
hypoesthesia, hyposthenia, awakening at night. The sum of
the scores for each symptom determines the GSS [53].
In Italy, the Boston Carpal Tunnel Questionnaire
(BCTQ) is an increasingly used outcome measure in CTS
as it is patient-oriented, highly reproducible, and validated
in Italian language. In addition to symptoms (BCTQ
SYMP, 11-parameter scale), BCTQ also evaluates function
(BCTQ FUNCT, 8-parameter scale). Each parameter has a
5-point scale; higher scores indicate more-severe symptoms and lower function [29]. Obviously, among the outcome measures for CTS there may also be an improvement
in neurophysiologic parameters.
As regards the first point, there are scales for the evaluation of the best overall clinical improvement, indicated
as either Clinical or Patient Global Impression of Change
(CGI-C and PGI-C).
The pain visual analogue scale (VAS) is a widely used
tool for pain evaluation. The VAS scale is represented by a
100-mm line with anchor points of no pain on the left
extremity and worst pain imaginable on the right
extremity. Along with this, there are other numerical
scales, the most-frequently used of which is the 11-point
Lickert numerical scale. These scales assess pain intensity,
whereas its quality may be assessed with the Short Form
McGill Pain Questionnaire (SF-MPQ) [55]. Quality of life
assessment is performed with a scale called SF-36 QOL
[56].
As concerns follow-up, it has to be underlined that if
there is no emergency condition (progressively worsening
neurological deficit, risk of metastases or abscesses), conservative treatment may be followed for 46 weeks and
possibly resumed cyclically (Table 9).
Natural history
An observational study conducted on patients with idiopathic CTS reports symptom resolution within 6 months
without treatment in 34% of hands. Remission rates were
higher in younger subjects, in women, and in pregnant
women [57]. In another study, according to the parameter
examined, 2734% of hands showed spontaneous
improvement after 1015 months. The most-severe
patients had the greatest improvement. Favourable prognostic indicators included the short symptom duration and

Neurol Sci (2010) 31:243252

Table 10 Key points
Natural history
CTS may improve or resolve spontaneously

young age. Negative predictive factors included bilateral

symptoms and positive Phalen signs [58] (Table 10).

Appendix
Considerable contribution to the preparation of this document was obtained from an extensive number of Physicians
specialised in Neurology, Orthopaedics, Physiatrics, Pain
Therapy, and General Medicine, who supported us by
bringing in corrections, integrations, suggestions and, in
any case, in full agreement:
Sebastiano Adamo, Massimo Alunni, Gaetano Amorico,
Antonio Augusti, Mario Avalle, Giuseppa Barbera, Eugenio Barbieri, Massimo Baroncini, Angelo Bartesaghi,
Angela Bassani, Maurizio Bejor, Giuseppe Bernardi,
Antonio Bernardo, Claudio Boninsegna, Davide Bonomo,
Silvano Botteselle, Enrico Califano, Valeria Campanella,
Antonio Campisi, Riccardo Canero, Michele Capuano,
Antonio Carbonari, Fabio Carbone, Piero Cataldo, Antonino Catanese, Antonio Cazzato, Riccardo Cecchetti,
Francesco Chilelli, Alessandro Ciarimboli, Mario Ciarimboli, Giovanni Cilia, Roberto Conigliaro, Roberto Corezzola, Renzo Cosso, Ettore Costabile, Domenico Cremonesi,
Marcello Cusitore, Michele DArienzo, Antonio DAura,
Vincenzo DOrsi, Angelo DAnnibale, Maurizio Dacco`,
Massimo Darbisi, Roberto De Masi, Paolo De Stefanis,
Vito De Tullio, Maria Teresa Desiato, Giuseppina Di
Stefano, Michele Dotta, Salvatore Emmola, Maurizio
Falso, Andrea Fedeli, Giovanni Ficola, Alfio Mauro Finocchiaro, Giulio Fiorenza, Sabino Fiume, Michele Formoso, Elio Fortuna, Andrea Foti, Silvia Galeri, Raffaele
Gambardella, Renato Gatto, Elisena Geraci, Sergio Gigliotti, Letizia Giulia Mauro, Luigi Grompone, Vittorio
Guglielmo Grosso, Fabio Guerriero, Stefano Guidotti,
Raimondo Ibba, Francesco Indiano, Giovanni Italiano, Rita
lEpiscopo, Alessandro La Medica, Matteo Laringe, Rosita
Laurenti, Vincenzo Lo Scalzo, Mario Longo, Davide
Lucchi, Maria Lucia, Emanuele Lupetti, Vincenzo Roberto
Macr`, Marco Maltinti, Alessandro Mannoni, Roberto
Mantia, Fabrizio Mantia, Domenico Mantova, Marina
Carlotta Marazzi, Nicola Margiotta, Claudio Mariani,
Maria Letizia Marini, Angelo Claudio Marrone, Gianni
Martelli, Daniele Martini, Alfredo Mattaliano, Massimo
Maurencig, Giulio Mazzini, Rossella Medda, Alfonso
Megna, Oriano Mercante, Antonio Mileto, Carmelo Militello, Gaetano Militenda, Donatella Moci, Mario Mosconi,
Silvia Oldani, Maurizio Olivieri, Michele Olivieri,

251

Giuseppe Partexano, Elisa Pasqualetto, Alberto Pellegrinetti, Massimo Pettina`, Pietro Pinelli, Giovanni Pozzuoli,
Fausto Prete, Luca Puccetti, Antonino Pugliesi, Giovanni
Antioco Putzu, Raffaele Quaranta, Daniele Raimondi,
Giancarlo Rando, Fabrizio Rasi, Pietro Rettagliata, Leonardo Rivelli, Vincenzo Rollo, Pierpaolo Romani, Sergio
Ronco, Vincenzo Rossi, Alberto Sampietro, Antonino
Sanfilippo, Provvidenza Sansone, Giovanni Savoca, Giuseppe Scaglione, Antonio Scala, Francesco Sellitto, Agostino Spinelli, Fausto Stante, Walter Starace, Salvatore
Torre, Raffaele Torre, Lucia Toscani, Arturo Tricarico,
Enrico Trucco, Tobia Ulisse, Angelo Vetro, Cesarino Vezzosi, Massimo Vigilante, Renato Villaminar, Gennaro
Vitiello, Luciano Wolensky, Leonardo Wolensky, Giancarlo Za, Antonio Zampogna, Angelo Zuppardo.

References
1. The Cochrane Library (2008) The Cochrane Library, Issue X,
2008. Wiley, Chichester
2. Clinical Evidence, Edizione Italiana
3. PNLG (2004) Come produrre, diffondere e aggiornare raccomandazioni per la pratica clinica. MANUALE METODOLOGICO. Aggiornamento Maggio 2004
4. Burns TM (2005) Mechanisms of acute and chronic compression
neuropathy. In: Dyck PJ, Thomas PK (eds) Peripheral Neuropathy, vol 4 (2). Elsevier Saunders, Philadelphia, pp 13911402
5. De Krom e coll (1992) Prevalence of carpal tunnel syndrome. J
Clinic Epidemiol 45:373376
6. Mondelli M, Giannini F, Giacchi M (2002) Carpal tunnel syndrome incidence in a general population. Neurology 58:289294
7. Bot S, van der Waal J, Terwee C et al (2005) Incidence and
prevalence of complaints of the neck and upper extremity in
general practice. Ann Rheum Dis 64(I):118123
8. European Agency for Safety and Health at Work (1999) Work
related neck and upper limb musculoskeletal disorders. Office for
Official Publication of the European Communities, Luxembourg
9. La Medicina del Lavoro (1996) 87 Numero monografico contenente metodi di analisi, studi ed esperienze di prevenzione per
le affezioni muscolo scheletriche da sovraccarico biomeccanico
degli arti superiori
10. Quality Standard Subcommittee of the American Academy of
Neurology (1993) Practice parameter for carpal tunnel syndrome
(Summary statement) Neurology 43:24062409
11. Jablecki CK, Andary MT, Floeter MK, Miller RG, Quartly CA,
Vennix MJ, Wilson JR, American Association of Electrodiagnostic Medicine, American Academy of Neurology, American
Academy of Physical Medicine, Rehabilitation et al (2002)
Practice parameter: electrodiagnostic studies in carpal tunnel
syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the
American Academy of Physical Medicine and Rehabilitation.
Neurology 58:15891592
12. INAIL RAPPORTO ANNUALE 2004 (2005) Roma, luglio 2005
http://www.inail.it
13. Colombini D, Occhipinti E, Cairoli S et al (2003) Le affezioni
muscoloscheletriche degli arti superiori e inferiori come patologie professionali; quali e a quali condizioni. Documento di consenso di un gruppo di lavoro nazionale. Med Lav 94(3):312329

123

252
14. Netter (2007) Neurologie. Thieme. II edn, p 408
15. DArcy CA, McGee S (2000) Does this patient have carpal tunnel
syndrome? JAMA 283:31103117
16. Katz JN, Stirrat C, Larson MG et al (1990) A self administered
hand symptom diagram in the diagnosis and epidemiologic study
of carpal tunnel syndrome. J Rheumathol 17:14951498
17. Padua L, Lo Monaco M, Padua R et al (1997) Neurophysiological
classification of carpal tunnel syndrome: assessment of 600
symptomatic hands. It J Neurol Sci 18:145150
18. http://www.gruppo-italiano-neuropathies.it/CTS/Default.htm
19. Uchiyama S, Itsubo T, Yasutomi T et al (2005) Quantitative MRI
of the wrist and nerve conduction studies in patients with idiopathic carpal tunnel syndrome. J Neurol Neurosurg Psychiatry
76:11031108
20. Martins RS, Siqueira MG, Simplicio H et al (2008) Magnetic
resonance imaging of idiopathic carpal tunnel syndrome: correlation with clinical findings and electrophysiological investigation. Clin Neurol Neurosurg 110:3845
21. Bland JD (2007) Treatment of carpal tunnel syndrome. Muscle
Nerve 36:167171
22. Cranford CS et al (2007) Carpal tunnel syndrome. J Am Acad
Orthop Surg 15:537542
23. OConnor D et al (2003) Non surgical treatment of CTS. Cochrane Database of Systematic Reviews
24. Padua L et al (2001) Multiperspective follow-up of untreated
carpal tunnel syndrome: a multicenter study. Neurology 56:1459
1466
25. De Grandis D (1998) Tolerability and efficacy of L-acetylcarnitine in patients with peripheral neuropathies. A short term open
multicentre study. Drug Invest 15(2):7379
26. Annette A. M. Gerritsen et al (2002) Conservative treatment
options for carpal tunnel syndrome: a systematic review of randomised controlled trials. J Neurol 249:272280
27. Ebenbichler GR, Resch KL, Nicolakis P et al (1998) Ultrasound
treatment for treating the carpal tunnel syndrome: randomised
sham controlled trial. BMJ 316:730735
28. Oztas O, Turan B, Bora I, Karakaya MK (1998) Ultrasound
therapy effect in carpal tunnel syndrome. Arch Phys Med Rehabil
79:15401544
29. Levine DW, Simmons BP, Koris MJ et al (1993) A self-administered questionnaire for the assessment of severity of symptoms
and functional status in carpal tunnel syndrome. J Bone Joint
Surg Am 75:15851592
30. Manente G, Torrieri F, Di Blasio F et al (2001) An innovative
hand brace for carpal tunnel syndrome: a randomised controlled
trial. Muscle Nerve 24:10201025
31. Burke TD, Burke MM, Stewart GW, Cambre A (1994) Splinting
for carpal tunnel syndrome: in search of the optimal angle. Arch
Phys Med Rehabil 75:12411244
32. Asworth N (2007) Carpal tunnel syndrome (Clin Evid Conc). Am
Fam Physician 75:381383
33. Walker WC, Metzler M, Cifu DX, Swartz Z (2000) Neutral wrist
splinting in carpal tunnel syndrome: a comparison of night-only
versus full-time wear instructions. Arch Phys Med Rehabil
81:424429
34. Akalin E, El O, Peker O et al (2002) Treatment of carpal tunnel
syndrome with nerve and tendon gliding exercises. Am J Phys
Med Rehabil 81:108113
35. Beckerman H, de Bie R, Bouter L, de Cujper H, Oostendorp R
(1992) The efficacy of laser therapy for muscoloskeletal and skin
disorder. Phys Ther 72:483491
36. Ernst E, Fialka V (1993) Low-dose Laser therapy: critical analysis of clinical effect. Schweiz Med Wochenschr 123:949954
37. Fortuna D, Zati A, Mondardini P, Ronconi L, Paolini C, Bilotta
TW (2002) Low level laser therapy ed efficacia clinica. Medicina
dello sport

123

Neurol Sci (2010) 31:243252

38. Tuner J, Hode L (2002) Laser-therapy: clinical practice and scientific background. Prima Books Grangesberg (Svezia)
39. Bland JD (2007) Treatment of carpal tunnel syndrome. Muscle
Nerve 36:167171
40. Gerritsen AA, de Vet HC, Scholten RJ, et al (2002) Splinting
versus surgery in the treatment of carpal tunnel syndrome. JAMA
288:12451251
41. Ly-Pen D, Andreu JL, de Blas G et al (2005) Surgical decompression versus local steroid injection in carpal tunnel syndrome:
a one-year, prospective, randomized, open, controlled clinical
trial. Arthritis Rheum 52:612619
42. Garland H, Langworth EP, Taverner D, Clack JMP (1964) Surgical treatment for the carpal tunnel syndrome. Lancet
1(7343):11291130
43. Verdugo RJ, Salinas RS, Castillo J, Cea JG (2003) Surgical
versus non-surgical treatment for carpal tunnel syndrome. In: The
Cochrane Library, vol 3, p CD001552
44. Scholten RJ, Mink van der Molen A, Uitdehaag BM, Bouter LM,
de Vet HC (2007) Surgical treatment options for carpal tunnel
syndrome. Cochrane Database Syst Rev 17(4):CD003905
45. Thoma A, Veltri K, Haines T et al (2004) A meta-analysis of
randomized controlled trials comparing endoscopic and open
carpal tunnel decompression. Plast Reconstructr Surg 114:1137
1146
46. Wong KC, Hung LK, Ho PC, Wong JMW (2003) Carpal tunnel
release: a prospective, randomized study of endoscopic versus
limited-open methods. J Bone Joint Surg Br 85B:863868
47. Saw NL, Jones S, Shepstone L et al (2003) Early outcome and
cost-effectiveness of endoscopic versus open carpal tunnel
release: a randomized prospective trial. J Hand Surg 28B(5):444
449
48. Jan C, Hammerstein S, Brock M (2001) Carpal tunnel syndrome:
a review of endoscopic release of the transverse carpal ligament
compared with open carpal tunnel release. Neurosurg Q 11:1725
49. Finsen V, Andersen K, Russwurm H (1999) No advantage from
splinting the wrist after open carpal tunnel release. A randomized
study of 82 wrists. Acta Orthop Scand 70:288292
50. Bury TF, Akelman E, Weiss AP (1995) Prospective, randomized
trial of splinting after carpal tunnel release. Ann Plastic Surg
35:1922
51. Cook AC, Szabo MRI, Birkholz SW, King EF (1995) Early
mobilization following carpal tunnel release. A prospective randomized study. J Hand Surg (Br) 20:228230
52. Chapman CR, Casey KL, Dubner R, Foley KM, Gracely RH,
Reading AE (1985) Pain misurement: an overview. Pain 22:131
53. Galer BS, Jensen MP (1997) Development and preliminary validation of a pain measure specific to neuropathic pain: the neuropathic pain scale. Neurology 48:332338
54. Levine DW, Simmons BP, Koris MJ et al (1993) A self-administered questionnaire for the assessment of severita` of symptoms
and functional status in carpal tunnel sindrome. J Bone Joint Surg
Am 75:15851592
55. Negri E, Bettaglio R, Demartini L, Allegri M, Barbieri M, Miotti
D, Paulin L, BuonocoreM, Bonezzi C (2002) Validation of the
Italian version of the neuropathic pain scale and its clinical
applications. Minerva Anestesiol 68:95104
56. Ware JE, Sherbourne CD (1992) The MOS 36-item short-form
health survey (SF-36) I. Conceptual framework and item selection. Medical Care 30:473483
57. Fatami T, Kobayashi LA, Utika T, Endoh T, Fujita T (1997)
Carpal tunnel syndrome; its natural history. Hand Surgery 2:129
130
58. Padua L, Padua R, Aprile I et al (2001) Multiperspective followup of untreated carpal tunnel syndrome. A multicenter study.
Neurology 56:14591466

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