Summary of intervention

Open or endoscopic surgical procedure to release median nerve from carpal    tunnel.

 

Number of CCG intervention 2017/18

44,497

 

Recommendation

  • Mild cases with intermittent symptoms causing little or no interference with sleep or activities require no treatment.
  • Cases with intermittent symptoms which interfere with activities or sleep should first be treated with:
  1. corticosteroid injection(s) (medication injected into the wrist: good evidence for short (8-12 weeks) term effectiveness)
    or
  2. night splints (a support which prevents the wrist from moving during the night: not as effective as steroid injections)
    • Surgical treatment of carpal tunnel should be considered if one of the following criteria are met:
  3. The symptoms significantly interfere with daily activities and sleep symptoms and have not settled to a manageable level with either one local corticosteroid injection and/or nocturnal splinting for a minimum of 8 weeks;
    or
  4. There is either:
    1. a permanent (ever-present) reduction in sensation in the median nerve distribution;
      or
    2. muscle wasting or weakness of thenar abduction (moving the thumb away from the hand).

Nerve Conduction Studies if available are suggested for consideration before surgery to predict positive surgical outcome or where the diagnosis is uncertain.

 

Rationale for recommendation

 

Carpal tunnel syndrome is very common, and mild cases may never require any treatment. Cases which interfere with activities or sleep may resolve or settle to a manageable level with non-operative treatments such as a steroid injection (good evidence of short-term benefit (8-12 weeks) but many progress to surgery within 1 year). Wrist splints worn at night (weak evidence of benefit) may also be used but are less effective than steroid injections and reported as less cost-effective than surgery.

 

In refractory (keeps coming back) or severe case surgery (good evidence of excellent clinical effectiveness and long term benefit) should be considered. The surgery has a high success rate (75 to 90%) in patients with intermittent symptoms who have had a good short-term benefit from a previous steroid injection. Surgery will also prevent patients with constant wooliness of their fingers from becoming worse and can restore normal sensation to patients with total loss of sensation over a period of months.

 

The hand is weak and sore for 3-6 weeks after carpal tunnel surgery but recovery of normal hand function is expected, significant complications are rare (≈4%) and the lifetime risk of the carpal tunnel syndrome recurring and requiring revision surgery has been estimated at between 4 and 15%.

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