Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Wrist splints (neutral or 20° extension) worn every night for 1 month. Uncommonly, splints can exacerbate CTS symptoms and/or cause additional pain and discomfort.
The patient should be referred to an occupational therapist or orthotist for custom-made splints if they have a hand/wrist deformity, or are unable to find a splint that is comfortable.
Activities that particularly provoke symptoms should be limited or modified.
In pregnancy, symptoms can appear rapidly and worsen rapidly, which may require aggressive intervention and close monitoring (both clinically and electrophysiologically).
Typically, it is recommended to persevere with a wrist splint given that after delivery, symptoms usually quickly dissipate within several weeks.
Wrist splints (neutral or 20° extension) worn every night for a trial of 1 to 2 months (mild 1-2 months; moderate up to 1 month). Uncommonly, splints can exacerbate CTS symptoms and/or cause additional pain and discomfort.
The patient should be referred to an occupational therapist or orthotist for custom-made splints if they have a hand/wrist deformity, or are unable to find a splint that is comfortable.
Activities that particularly provoke symptoms should be limited or modified.
Primary options
methylprednisolone acetate: single doses of 20-80 mg intracarpally with or without a local anaesthetic have been reported; however, consult a specialist for further guidance on dose
OR
dexamethasone: single doses of 4 mg intracarpally with or without a local anaesthetic have been reported; however, consult a specialist for further guidance on dose
OR
hydrocortisone: single doses of 25-100 mg intracarpally (as hydrocortisone succinate) have been reported; however, consult a specialist for further guidance on dose
If response to splinting is unsatisfactory, intracarpal injection of corticosteroid may be tried, in addition to splinting. There is no clear consensus on type or dose, which is often administered with a local anaesthetic (e.g., 0.5 to 1 mL of 2% lidocaine).
Most patients respond to corticosteroid injections in the first month, and the benefit may last for several months in some individuals.
If the patient requires more than 2 injections in 12 months, they should be considered for referral for surgical release.
Patients should be referred for surgical release as soon as possible, as the risk of permanent nerve damage is a possibility. It is unclear whether any specific rehabilitation after surgery is helpful.[89]
Splints are recommended to be trialled for up to 1 month before considering corticosteroid injection. If splints plus corticosteroid (or splinting alone if the patient declines corticosteroid) fail, then the patient may be referred for surgical release. It is unclear whether any specific rehabilitation after surgery is helpful.[89]
Conservative therapy is started with wrist splints and corticosteroid injection while awaiting EMG studies.
The original diagnosis should be re-confirmed and consideration given to whether an additional diagnosis is also present (e.g., polyneuropathy, radiculopathy).
With failure of conservative management or severe CTS on EMG studies, the patient should be referred for repeat carpal tunnel release. It is unclear whether any specific rehabilitation after surgery is helpful.[89]
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