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This commissioning statement refers to:
Where a diagnosis of CTS is certain (where there is diagnostic uncertainty a specialist opinion is required) and one of the follwoing criteria:
Patients should make shared decisions with clinicians, using decision support such as the NHS Decision Aid for Carpal Tunnel
NOTE: Nerve conduction studies are NOT generally needed to confirm the diagnosis. In elderly patients, with insidious onset nerve conduction studies may be useful to assess severity.
CTS is a condition that involves pain and tingling in the first three or four fingers of one or both hands, which usually occurs at night. It is caused by pressure on the median nerve as it passes under the strong ligament that lies across the front of the wrist. Mild or moderate symptoms often resolve within 6 months1. This is most likely to occur in young people (less than 30 years of age), if the symptoms are unilateral and of short duration, and in women in whom fluid retention due to pregnancy is the precipitating factor. With wearing a wrist splint that maintains the wrist at a neutral angle without applying direct compression, any improvement should be apparent within 12 weeks of use1.
Acupuncture may be effective for pain relief in the short-term, although there is no therapeutic benefit. Minimization of activities that exacerbate symptoms may help, but for people who work with computer keyboards there is little evidence to suggest that modifications at their work place are likely to be of any help in relieving symptoms1.
CTS can also be a progressive condition, but many patients have a satisfactory response to conservative management. If CTS does not respond to conservative treatment within 6 months, evidence suggests that it is unlikely to respond at all.
GPs are advised to pursue conservative options for treatment of mild to moderate CTS cases. Only where the case is severe, or where a moderate case persists and fails to respond to a minimum of 6-months' conservative treatment should a referral to secondary care be considered.
A systematic review2 concluded that
Surgical carpal tunnel decompression can provide permanent and complete cure in most cases of severe CTS but it is not without risk. A survey of over 4000 patients having surgery under usual NHS circumstances found that about two years after surgery, only 75% considered the operation an unqualified success and 8% thought that they were worse off3, 4 Reasons why the operation sometimes may not relieve symptoms include:
Overall, patients whose CTS symptoms are significantly troublesome and who have mild or moderate impairment of the median nerve function should be offered splinting and local steroid injection. Patients failing such conservative management and those who present at a later stage with objective neurological signs or delayed motor conduction on nerve conduction systems should be offered the option of surgical decompression. All should be advised of the potential risks of the different treatments4.