Ergonomic keyboard. Patients who use computers at work may find that an ergonomic keyboard helps to relieve pain associated with CTS, compared with a standard keyboard.33
Therapeutic ultrasound. A recent meta-analysis found that there is only poor-quality evidence for ultrasound as an effective treatment for CTS—a process in which a round-headed instrument applied to the skin delivers sound waves that are absorbed by underlying tissues in the carpal tunnel. And there is insufficient evidence for one type of ultrasound over another, or to suggest that ultrasound is more effective than other nonsurgical treatments.34 Notably, ultrasound takes several weeks to provide a therapeutic benefit.
What about acupuncture? A recent trial found that acupuncture was no more effective than sham acupuncture in relieving symptoms of CTS in patients wearing wrist splints.35 Magnet therapy, chiropractic, and cold laser therapy are not supported by evidence either.28
Is the patient a candidate for surgery?
Carpal tunnel release provides good long-term outcomes for 70% to 90% of patients and is a cost-effective treatment.36,37 Evidence supports a trial of conservative therapy, however, before considering surgery for patients with mild-to-moderate CTS.22 Future studies are needed to identify prognostic characteristics of patients most likely to respond to each type of intervention, and the optimal timing for surgical release.
Patients with severe CTS—with findings such as thenar atrophy, diminished hand function, and median nerve denervation—should be referred for surgery without delay. This recommendation is based on expert opinion, however, as most clinical trials comparing surgical vs nonsurgical treatment exclude those with severe CTS.38
3 surgical techniques, and a novel approach
Surgical techniques include open, endoscopic, and minimal incision carpal tunnel release, with benefits and drawbacks for each. Compared with open release, for example, patients who undergo endoscopic release have less postoperative pain at 12 weeks, quicker return to work, and fewer wound complications, but are more likely to require surgical revision. And minimal incision release is associated with improved symptoms and function compared with open release.38 However, there is no long-term evidence that any one of these 3 surgical approaches is more effective than another.39
Percutaneous carpal tunnel release is a novel approach that may be offered in outpatient settings, with local anesthesia and ultrasound guidance to avoid median nerve damage.40 Because studies of the safety and efficacy of percutaneous carpal tunnel release are limited, however, this approach is considered experimental.41 Percutaneous release is not a treatment recommended by the AAOS.38
What to tell patients about postop care
Regardless of the method used for carpal tunnel release, most complications are minor—eg, a painful or hypertrophic scar, stiffness, swelling, and pain or tenderness on either side of the incision—and resolve within a few months.42 Advise patients not to continue to wear a wrist splint after surgery; doing so can cause stiffness or adhesions and may compromise surgical outcomes.41 Postoperatively, patients should be instructed to do nerve gliding exercises and to massage their scars, both of which they can safely do at home.43
Patients can expect significant symptomatic improvement within 1 week of surgery, and most will be able to return to normal activities in 2 weeks.44 Those with severe CTS should be warned, however, that it could take up to a year to determine the extent of recovery.22 Evidence suggests that from 3% to 19% of patients may have persistent or recurrent symptoms even after carpal tunnel release, with up to 12% requiring surgical revision.45
CASE When Ms. K returns, she reports that while there has been some improvement, some activities—such as driving long distances and talking on the phone—still cause numbness and tingling. And, if she doesn’t wear the splint at night, she awakens with tingling in her hands. You discuss 2 options—continued conservative treatment with a local steroid injection, or EDS and surgical referral. The patient opts for the injection and continued use of the nocturnal wrist splint and exercises. When she returns in another 6 weeks, Ms. K reports significant improvement. You agree to stop the wrist splint and exercises and advise her to follow-up on an as-needed basis if the symptoms return.
CORRESPONDENCE Jennifer Wipperman, MD, MPH, Via Christi Family Medicine, 1121 S. Clifton, Wichita, KS 67218; jennifer.wipperman@viachristi.org