CARPAL TUNNEL SYNDROME

I. Diagnosis:

  1. Provocative test: "wrist flexion/nerve compression"--pt flexes wrist to 60' and examiner provides constant digital pressure w/one thumb over the median nerve at the carpal tunnel for up to 30sec. Had sig. higher sensitivity & specificity in identifying nn-conduction-study-proven CTS c/w Phalen's and Tinel's tests (J. Bone Joint Surg. Br. 80-B:493, 1998--JW)

II. Treatment:

  1. Ultrasound QD x 10d then BIW x 5wks in mild-mod CTS was sig. better than a "sham" placebo tx (satisfactory improvement in 68% vs. 38% of cases at end of tx) (BMJ 316:731, 1998--AFP)
  2. Corticosteroids
    1. ORAL: Only prednisolone (20mg/d x 2wks then 10mg/d x 2 wks) resulted in sig. improved sx scores c/w placebo in a trial 73 pts with CTS confirmed with electrodiagnostic studies w/o obvious underlying causes, e.g. hypothyroidism, pregnancy, or DM. Other comparison tx's were trichlormethiazide, a diuretic, or tenoxicam, an NSAID) (Neurol. 51:390, 1998--JW)
    2. INJECTED: Injection just proximal to the carpal tunnel of methylprednisolone (vs. injection of placebo) ass'd with sig. less sx at 12mos in a ranodmized trial of 30 pts with CTS (BMJ 319:884, 1999--JW)
    3. ORAL VS. INJECTED: 60 pts with CTS randomized to 15mg methylprednisolone injected into carpal tunnel vs. oral methylprednisolone 25mg/d x 10d; both groups had sig. improvement in sx scores at 2wks but only injection group had sig. improvement at 3mos (Neurol. 56:1565, 2001--JW)
  3. Yoga
    1. 42 pts w/CTS randomized to upper-body yoga x 8wks vs. wrist splinting. At 8wks, yoga group had sig. > improvement in grip strength and pain c/w controls; no diff. in median n. conduction time (JAMA 280:1601, 1998)
  4. Wrist splinting
    1. In a randomized trial of pts with electrodiagnostic-proven CTS all given custom-made neutral position splint,  full-time splinting vs. splinting only when asleep ass'd with electrodiagnostic and sx measures at 6wks (???journalal 81:424, 2000--AFP)
  5. Surgery: Carpal tunnel release
    1. In a randomized trial of 176 pts with severe CTS (confirmed by electrodiagnostic testing), surgery vs. nightly wrist splinting symptom scores at 18mos were sig. better in surgery group (JAMA 288:1245, 2002--JW)
  6. Surgery vs. local steroid injection
    1. In a study in 101 pts with CTS (163 wrists total) unresponsive to NSAIDs and splinting randomized to surgery vs. local corticosteroid injection, the surgery wrists had sig. greater improvement in sx but there were no sig. diffs. at 6mos or 12mos (Arth. Rheum. 52:612, 2005--JW)