Carpal Tunnel Syndrome – Surgery or Not?

This may be a good day to look at the best treatment for carpal tunnel syndrome, which is almost always caused by work-related repetitive movements, such as keyboarding. The disabling syndrome is caused by compression of the median nerve as it passes through a narrow passage on the front of the wrist. Symptoms include tingling, numbness, and pain that can radiate from the hand to the forearm of even the shoulder. Most cases are treated non-surgically, but there’s controversy as to whether non-surgical approaches are effective. In 2003 there was a British review that concluded that there was no evidence of benefit from non-surgical interventions, but this excluded the possibility that steroid injections might be effective. The best treatment has formed the subject of a recent Cochrane Review .

A search was made for reports on all randomized trials comparing any type of non-surgical therapy with any type of surgical treatment. Only 4 clinical trials, however, could be found; they covered a total of 317 patients. Two studies compared surgical opening of the tunnel by cutting the carpal ligament with splinting the wrist for one month or overnight splinting for at least 6 weeks. The outcome – clinically-relevant improvement in symptoms at the 3-month interval - significantly favored surgery. (Clinically-relevant improvement was defined as a 50% reduction in pain and tingling or improvement in function.) After 6 months, the results continued to favor surgery.

The other two studies, which were smaller, compared steroid injection with surgical decompression. In one, steroids resulted in more frequent improvement in nighttime tingling. In the other, more surgical patients had a 50% improvement in overall symptoms. In other words, it’s ‘a wash’.

In all 4 studies there were complications of treatment – more with surgery than with non-surgical therapy. But a significant number of those treated medically required surgery, eventually.

It seems clear that surgery is superior to splinting, and possibly is superior to steroid injections. However, better studies are needed to shore up these impressions; and there’s always room for improved surgical technique to reduce the number of complications (stiffness, discomfort, and wound hematoma) . . .