In this blog for people with carpal tunnel syndrome (CTS), Sarah Chapman looks at the evidence for surgical and non-surgical treatments for CTS, talks to Consultant Neurophysiologist and Cochrane Review author Jeremy Bland, and reflects on her husband’s experiences. She is returning to this topic, four years after first writing about it here, to bring you the latest evidence and resources.
An update of the Cochrane Review comparing steroid injection with surgery for carpal tunnel syndrome will be published this year and will be added to the blog.
Page originally published: 7 December 2018. Revised and republished 15 February 2023. Page updated 3 March 2023.
Carpal tunnel syndrome (CTS) is described on the NHS page as “pressure on a nerve in your wrist”. More precisely, the median nerve is compressed in the carpal tunnel, a passageway between structures at the heel of your hand. This causes symptoms such as pain, tingling and numbness in the fingers, and these tend to wake the person at night.
Consultant Neurophysiologist Jeremy Bland told me “I quite often hear from patients that ‘I didn’t think it could be CTS because I didn’t have any pain’. A substantial number of patients with CTS do not get any pain at all. It’s important for people to know that the defining symptom is tingling and numbness and not put off going to a doctor because they don’t have pain and so think the problem can’t be CTS”.
My husband Tim, on the eve of surgery for CTS, described his experience of it as “incredible pain on trying to use my hands, lack of real sensation combined with phantom sensation, and lack of sleep due to pain”. It made working impossible. Spending much of every night out of bed, getting what little relief he could by standing up, the only beneficiary was our cat, who now had company round the clock.
While painkillers may give some relief in the short term, the mainstays of treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. are splinting and/or hand exercises, steroid injection and surgery. Tim went through all of these. We’d looked at the evidence for these and other approaches to treating CTS, from a number of Cochrane ReviewsCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research., and found that it was mostly very poor, so there was a great deal of uncertainty about the benefits and harms of treatments.
Four years on, while CTS is just a bad memory for Tim, it is good to see new and updated Cochrane Reviews on CTS to inform treatment decisions. The above treatment options, along with lifestyle changes, are all included in the Clinical Knowledge Summary on Carpal tunnel syndrome from NICE (National Institute for Health and Care Excellence).
Non-surgical treatments for carpal tunnel syndrome
Use of a wrist splint at night will commonly be offered to people with mild to moderate symptoms of CTS. Tim found that helpful some of the time but horrible in hot weather. The NHS decision aid Making a decision about carpal tunnel syndrome says if this option works for you, your symptoms should start to improve within a few nights.
An update of the Cochrane Review Splinting for carpal tunnel syndrome was published in February 2023. The authors conclude “There is insufficient evidence to conclude whether splinting benefits people with CTS. Limited evidence does not exclude small improvements in CTS symptoms and hand function, but they may not be clinically importantClinical significance is the practical importance of an effect (e.g. a reduction in symptoms); whether it has a real genuine, palpable, noticeable effect on daily life. It is not the same as statistical significance. For instance, showing that a drug lowered the heart rate by an average of 1 beat per minute would not be clinically significant, as it is unlikely to be a big enough effect to be important to patients and healthcare providers., and the clinical relevance of small differences with splinting is unclear.” They also find that:
- people may have a more chance of overall improvement with night‐time splints than with no treatment
- it is uncertain whether it is best to wear splints all the time or only at night, and how long-term use compares with short-term use
- it is uncertain whether wearing splints reduces the need for surgery
- splinting may cause temporary side effects such as difficulty in falling asleep or transient tingling after removal of the splint; none of the trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. reported any serious side effects
There were not quite two thousand people in the 29 included trials; most had mild-to-moderate symptoms and there were more women (81%) than men. None had had surgery for CTS.
The NHS page on CTS says there is “a small amount of evidence to suggest hand exercises help ease the symptoms of CTS”.
This is essentially about avoiding or reducing activities that increase CTS symptoms, usually activities where you bend your wrist, use vibrating tools or grip something hard. You might need a workplace assessment, depending on your job.
Local steroid injection
A single steroid injection into the carpal tunnel has been a treatment option for a long time but its usefulness is still debated. Now, a Cochrane Review Local corticosteroid injection versus placebo for carpal tunnel syndrome (published February 2023) has brought together the evidence on the effects of steroid injection into the wrist, compared with placeboAn intervention that appears to be the same as that which is being assessed but does not have the active component. For example, a placebo could be a tablet made of sugar, compared with a tablet containing a medicine. (an injection with a fluid that doesn’t have an active ingredient), for carpal tunnel syndrome.
The 639 people in the nine included studies had mild or moderate CTS and no other conditions that often go along with it, such as arthritis or diabetes. So the evidence can’t tell us about the effects of steroid injection for people with severe CTS and/or co-existing health problems.
The evidence suggests that local steroid injection:
- probably improves symptoms and hand function at up to three months
- probably improves nerve conduction
- may improve quality of life at three months
- may reduce the need for surgery up to 12 months
Unwanted effects were uncommon and where serious harms were reported, they were rare.
Jeremy Bland, one of the authors of the review, says there isn’t much doubt that steroid injection improves hand function, but of course not for everyone. He explains: “Not everyone responds to steroids at all, but about 80% do. Relapses are common and can occur at any time after injection. In my experience, about half of the patients who get a good response to steroids relapse within a year and the other half are still OK one year post injection. On average patients are better at 3 months post injection but some will not have responded to start off with, some will have already relapsed, and some will be fine. So the reality is more complex than the evidence summary might suggest.
Tim didn’t get the benefit he hoped for from a steroid injection and moved on to surgery.
Other non-surgical treatments
There are many unproven treatments for CTS. You can find out more at www.carpal-tunnel.net, a website with trustworthy information about CTS maintained by Jeremy Bland.
Surgery for carpal tunnel syndrome
Surgical treatment involves releasing pressure on the nerve by cutting the transverse carpal ligament. This can be done with open surgery or endoscopically. It usually takes about 20 minutes and you don’t need to stay in hospital overnight. Surgery usually improves symptoms straightaway.
A Cochrane Review on Endoscopic release for carpal tunnel syndrome (published January 2014) included studies comparing this approach with open release. Drawing mostly on low-certainty evidence, the authors found that the two approaches may be comparable in relieving symptoms and improving function, although endoscopic release probably results in a greater improvement in grip strength and may be associated with fewer minor complications. They found no difference in the incidenceThe number of new occurrences of something in a population over a particular period of time, e.g. the number of cases of a disease in a country over one year. of serious complications, which were few.
Jeremy Bland tells me that, since this review was published, emerging evidence suggests there is little real difference between the two approaches and that endoscopic release is more expensive.
With a choice of absorbable or non-absorbable material used to stitch the wound after carpal tunnel surgery, is one better than the other? This Cochrane Review (published February 2018) highlighted uncertainty about how they compare in terms of pain, hand function, scar satisfaction or wound inflammation, due to very low-certaintyThe certainty (or quality) of evidence is the extent to which we can be confident that what the research tells us about a particular treatment effect is likely to be accurate. Concerns about factors such as bias can reduce the certainty of the evidence. Evidence may be of high certainty; moderate certainty; low certainty or very-low certainty. Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of evidence. Find out more here: https://training.cochrane.org/grade-approach evidence. However, there’s an obvious advantage with absorbable stitches, which is that they don’t need removing.
Researchers have explored the factors that might predict how successful surgery is likely to be. Factors that may be linked with better outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’. include:
- having moderately severe, rather than very mild or very severe, nerve conduction abnormalities
- night waking
- a family history of carpal tunnel syndrome
- a good response to corticosteroid injection
- being female
Whereas certain factors may be linked with poorer outcomes:
- greater functional impairment
- surgery on the dominant hand
You can put in details of these things in your own case in the surgical prognosis calculator at www.carpal-tunnel.net to see whether you are likely to benefit from surgery.
Rehabilitation after surgery
So after the surgery, then what? Our memories of Tim’s post-operative recovery are now hazy but he was able to travel to London the next day and was more comfortable than he’d been for a long time. Beyond that, we have gratefully consigned it to history.
The Cochrane Review on rehabilitation after carpal tunnel release (published February 2016) includes a dizzying array of possibilities from immobilization using a wrist orthosis to ice therapy, exercise and scar desensitization and a glaring lack of reliable evidence. Decisions about treatment ideally take into consideration evidence, clinical judgement and patient preference, and this is reflected in the authors’ conclusions:
“People who have undergone CTS surgery should be informed about the limited evidence of effectivenessThe ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. of postoperative rehabilitation interventions. Until researchers provide results of more high‐quality trials that assess the effectiveness and safetyRefers to serious adverse effects, such as those that threaten life, require or prolong hospitalization, result in permanent disability, or cause birth defects. of various rehabilitation treatments, the decision to provide rehabilitation following CTS surgery should be based on the clinician’s expertise, the patient’s preferences and the context of the rehabilitation environment.” Jeremy adds that rehabilitation should be directed at specific problems, so if a patient has finger stiffness that will need a different approach to scar thickening and tenderness, for example.
The NHS decision aid and the leaflet from the Royal College of Surgeons (see below) both give some information and advice about driving and returning to work.
Information and resources for people with carpel tunnel syndrome
- The Versus Arthritis (website www.versusarthritis.org) leaflet Carpal tunnel syndrome.
- The NHS (website www.nhs.uk) leaflet Carpal tunnel syndrome.
Making decisions about treatment
- NHS Making a decision about carpal tunnel syndrome (CTS)
- The Evidently Cochrane blog Making health decisions: things that can help isn’t specific to CTS but looks at some key things for making a treatment decision that is right for you
What to expect after surgery
- The Royal College of Surgeons of England (RCSEng; website www.rsceng.ac.uk) patient leaflet Carpal tunnel release
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This web site is my intake, really fantastic design and Perfect articles.
First of all I have to declare an interest as one of the authors of the forthcoming revision of the steroid treatment review. As it’s not out yet I can’t say much about the findings but it’s fair to say that there is a considerable amount of new evidence to add to the old review. The story of a very painful, ineffective injection is interesting. We have studied injection pain in a series of over 1000 injections and the mean score on a conventional 0-10 pain scale is about 2 so if these injections are done competently they really should NOT be very painful. The commonest reason for a severely painful injection is misplacement of the needle in the median nerve rather than in the surrounding tissues. Intraneural injection IS very painful and, depending on what is injected, can probably cause further median nerve injury in some cases, though we are currently involved in following up 22 probable cases and most do seem to have made a long term satisfactory recovery. One would therefore wonder if Tim’s injection was intra-neural, which would account for both the pain and the lack of efficacy. About 80% of CTS patients do gain at least short-term relief from steroid injection. There is hardly any evidence relating to second and subsequent injections either and the topic of managing CTS with serial injections also needs study, despite eh fact that this approach is frequently used in general practice and rheumatology.
Your rather depressing review of the state of evidence for almost everything else in the blog is, alas, accurate, and it is sad that such a common, and easy to study condition as CTS does not have a better evidence base for treatment. We are just about to publish a further RCT of ultrasound treatment which will no doubt be added to that analysis. There is no doubt however that surgery is ‘effective’ in alleviating symptoms, despite its recent inclusion in an NHSE list of procedures of limited clinical effectiveness (NHSE have since modified the language of this a bit).
You make no mention of nerve conduction studies as a means of evaluating the severity of the nerve damage. There is no Cochrane review on the topic so that is perhaps understandable but it is an area of considerable controversy between ourselves in neurophysiology and the hand surgeons… and another area which is crying out for some well designed studies – the one published study which purports to show that management without NCS is as successful as management with them is a prime example of methodology so inadequate that it can be used to teach what mistakes to avoid in experimental design.
Thank you very much for this detailed and helpful comment. I will be sure to update the blog when the steroid treatment review is published, and it’s good to hear there’s plenty of new evidence.
Tim was very interested to hear what you’ve told us here. He says the pain from the injection was easily 9 on 0-10 scale and his symptoms worsened afterwards. He did have nerve conduction tests and said that the person doing them was the first person to say, from touching his wrist, that he had severe CTS, where several physios and two GPs had been unclear. A great relief to him to get this done and then have surgery (second one to follow).
You are quite right that nerve conduction studies weren’t mentioned as there is no review on them and I don’t have specific expertise in this field. This is an example of why we delight in being able to get guest blogs, or comments to add to blogs, by people with relevant expertise, who can go beyond summaries of the reviews. Hmm, maybe we should think about a whole blog on the steroid review update? If so, I will be getting back to you!