Carpal Tunnel – Criteria Led Commissioning Statement

Scope

This commissioning statement refers to:

  • Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, which is a surgery in which the transverse carpal ligament is divided. It is a treatment for carpal tunnel syndrome.
  • The criteria for referral to secondary care for the treatment of carpal tunnel syndrome in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Status

Eligibility Criteria

Where a diagnosis of CTS is certain (where there is diagnostic uncertainty a specialist opinion is required) and one of the follwoing criteria:

  1. Moderate symptoms - The patient has not responded to a minimum of 3 months of conservative management, including:
    • >12 weeks of night-time use of wrist splints AND/OR Corticosteroid injections in appropriate patients
    • The symptoms are interfering with activities of daily living
  2. Advanced or severe neurological symptoms of CTS such as constant pins and needles, numbness, muscle wasting and prominent pain
  3. The patient is suffering from significant functional impairment*, pain or sleep deprivation
  • *Significant functional impairment is defined as a loss or absence of an individual's capacity to meet personal, social or occupational demands

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.

Lifestyle Factors - Best Practice

Obesity

  • Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
  • There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
  • See Weight Management Care Pathways

Smoking

  • In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
  • Smoking remains the leading cause of preventable morbidity and premature death in England.
  • There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
  • See Smoking Cessation Care Pathways
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Evidence/Rationale

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

  • Corticosteroids (local injection) and surgery versus no treatment are 'likely to be beneficial'
  • Surgery versus wrist splints or local corticosteroid injection are both 'a trade-off between benefits and harms'.
  • Therapeutic ultrasound and wrist splints are both of 'unknown effectiveness'.

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:

  • Misdiagnosis
  • Failure to fully divide the transverse carpal ligament
  • Delay of treatment to a point when median nerve function is beyond recovery
  • (A small minority are the result of more unpredictable surgical complications, inadvertent nerve and vessel lacerations, infections, painful scarring, and complex regional pain syndrome.)

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.

References

  1. NICE CKS Carpal tunnel syndrome http://cks.nice.org.uk/carpal-tunnel-syndrome#!scenariorecommendation:2
  2. Clinical Evidence – Carpal Tunnel Syndrome updated August 2014 http://clinicalevidence.bmj.com/ceweb/conditions/msd/1114/1114.jsp
  3. Bland JDP. Carpal tunnel syndrome. Curr Opin Neurol 2005;18:581-5. [PubMed]
  4. Bland J (2007) Clinical Review: Carpal tunnel syndrome. BMJ 2007;335;p343- 346 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1949464/
  5. BSSH Evidence for Surgical Treatment 1 - CTS 2010 http://www.bssh.ac.uk/education/guidelines/carpal tunnel syndrome.pdf
  6. Royal College of Surgeons Commissioning Guide: Treatment of painful tingling fingers (November 2013) - currently under review
  7. https://southwest.devonformularyguidance.nhs.uk/referral-guidance/western-locality/musculoskeletal/carpal-tunnel
  8. British Orthopedic Association - Commissioning guide: Treatment of painful tingling fingers https://www.boa.ac.uk/wp-content/uploads/2014/06/Treatment-of-painful-tingling-fingers_FINAL2.pdf
  9. Patient Info - Carpal Tunnel Syndrome https://patient.info/decision-aids/carpal-tunnel-syndrome-decision

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2018
  • Ref No: PA11 - 05.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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