Carpal Tunnel Syndrome:

What’s best available.

Syamsul Rizal AA
Sports Medicine
UMMC
 What do we know before?
• Analgesic: NSAID
• Steroids: local, systemic
• Other drugs: pyridoxine
• Wrist splints
• Electrotherapeutic and physical modalities
• Surgery
• Maybe none
 What do we know now?
Evidence-based medicine.

Best Practice BMJ.

 What should we do now?
Making the diagnosis

Ascertain patient’s clinical status

Treat the patient accordingly, evidence based

Onset Severity Treatment
Acute [Clinical diagnosis] Wrist splint
[Pregnant] •20 degrees vs neutral
• nocturnal, for 2/52

Mild 1st line Wrist splint

Moderate
2nd line Corticosteroid + wrist splint
*by EMG findings •Intracarpal injections
[non-pregnant] •If need more than twice per year, refer surgery
•Primary options are hydrocortisone, dexamethasone and
mehylprednisolone

adjunct Hydrochlorothiazide
• P/O 25-200md OD x 2/52
•Mainly used in edematous patients.

NSAIDS
•P/O ibuprofen 200-400mg TID, short course
•P/O celecoxib 200mg/day
•Indication: with significant inflammation or arthritis

Severe Surgical release

•ASAP if permanent nerve damage possible
*by EMG •Non-surgical measures unlikely beneficial
[non-pregnant]
Onset Severity Treatment

Ongoing Moderate [failed splint and steroid injections]

*by EMG findings Surgical release

Refractory to surgery •Recommence non-surgical therapies

• Wrist splints
Severe by EMG studies • Corticosteroid
• Adjuncts
•Revisit diagnosis
•Repeat carpal tunnel release
Patients with significant edema in the hand
and wrist region

• Initially wearing a wrist splint

• Mild diuretic (e.g., hydrochlorothiazide) is recommended [LoE:B]
• No response: consider corticosteroid injections [LoE:C]
• Still not responding: consider surgical release [LoE:C]
Patients with significant evidence of
inflammation (tendonitis or arthritis)
• Initial: wrist splint
• In addition, add NSAID [LoE;B]
• No response: consider steroid injection
• Still no response: consider surgical release
Pregnancy
• Symptoms can appear rapidly and worsen rapidly]
• Recommended to persevere with a wrist splint
• Not recommended to start on hydrochlorothiazide
Evidences
Effects of drug treatments for carpal tunnel syndrome:

• Beneficial
– Corticosteroid (local > systemic)
• Low quality evidence
• Not better than surgical release, but achieves faster result
• Not known: which, how much, how to
• Concern: may damage median nerve

• Unknown effectiveness
– NSAID
• Moderate quality evidence: better than placebo
• Very low quality evidence: less effective than steroid
• Can be used in tendonitis/arthritis
– Diuretics
• Moderate quality evidence to be no better than placebo
• Very low quality evidence: less effective than systemic steroid
• Very low quality evidence: as effective as NSAIDs
– Pyridoxine
• Very low quality evidence: not better than placebo,
Effects of non-drug treatments for carpal tunnel
syndrome:

• Unknown effectiveness:
– Acupuncture
– Massage
– Nerve and tendon gliding exercises
– Therapeutic exercises
– Wrist splints
• Compared with no treatment : improve after 2–4 weeks (moderate-quality
evidence).
• Compared with systemic corticosteroids : may be as effective after 3 months (low-
quality evidence).
• Compared with open surgery : less effective at reducing symptoms after 12–18
months (low-quality evidence).
• Neutral splint compared with 20 ° extension splint : both are equally effective (very
low-quality evidence).
• Full-time use of splint compared with nocturnal use alone:  Full-time use of a
neutral wrist splint may be no more effective at reducing symptoms after 6 weeks
than nocturnal use alone (low-quality evidence).
Effects of surgical treatments for carpal tunnel syndrome:

Trade off harm-benefit

• Endoscopic carpal tunnel release versus open carpal tunnel release:
– Both are equal (low quality evidence)
– Faster recovery with endoscopic surgery
• Surgery versus wrist splints:
– more effective at reducing symptoms after 12–18 (low quality evidence)
– No consensus for timing
• Surgery versus local corticosteroid
– may be as effective as local corticosteroid injections at reducing symptoms after
6–12 months, and may be less effective in the shorter term (low-quality
evidence).
Unknown effectiveness:
• Surgery versus no treatment
Wrist splints after carpal tunnel release surgery:
• may not improve symptoms, including grip strength,
compared with no restriction of movement (very low-quality
evidence)
• may increase the time off work compared with allowing
unrestricted movement (low-quality evidence).
Thank you.