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EDUCATION CLINICAL REVIEW
Carpal tunnel syndrome
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Scott D Middleton,1 Raymond E Anakwe2
1
Department of Trauma and
Orthopaedic Surgery, Royal
Infirmary of Edinburgh, Edinburgh,
UK
2
Department of Trauma and
Orthopaedic Surgery, St Mary’s
Hospital, Imperial College NHS
Trust, London W1 2NY, UK
Correspondence to: R E Anakwe
[email protected]
Cite this as: BMJ 2014;349:g6437
doi: 10.1136/bmj.g6437
Carpal tunnel syndrome is the most commonly diagnosed
compression neuropathy of the upper limb. Patients may
present to general practitioners, physiotherapists, hand
therapists, or surgeons with a variety of symptoms. Several studies have examined the epidemiology, diagnosis, and treatment of carpal tunnel syndrome. We review
these resources to provide an evidence based guide to
the diagnosis and treatment of carpal tunnel syndrome.
What is carpal tunnel syndrome and who gets it?
Carpal tunnel syndrome encompasses a collection of
symptoms: patients often mention altered sensation or
pain in the hand, wrist, or forearm. The reported prevalence of carpal tunnel syndrome is between 1% and 7%
in European population studies, and most studies cite a
figure of around 5%.1 2 It has been found to be three times
more common in women than in men.2
The pathology is believed to relate to compression,
entrapment, or irritation of the median nerve within the
carpal tunnel at the wrist: an anatomical space bounded
by the carpal bones dorsally and the fibrous flexor retinaculum volarly. In effect, anything that causes a reduction in the volume of this compartment or increases the
pressure within the compartment may precipitate or
cause the symptoms of carpal tunnel syndrome.
Most cases of carpal tunnel syndrome are idiopathic.
The symptoms of carpal tunnel syndrome have been estimated to be bilateral in up to 73% of cases, although they
may not manifest concurrently.3 4 Other causes or associations have been identified with pregnancy, overuse of
the hand or wrist, wrist trauma, obesity, hypothyroidism,
renal failure, diabetes, and inflammatory arthropathy.5
Evidence also suggests a genetic component for carpal
tunnel syndrome, although the exact basis of this has not
yet been established.6
Patients often report that symptoms are worse at night
or wake them from sleep. They may report aggravation of
symptoms with overuse of or heavy activities involving
the hand or wrist. Despite this, the evidence for occupation as a causative factor for carpal tunnel syndrome is
weak.7 8 Worsening of symptoms is not the obligatory
clinical course of the condition.9 How to identify those
THE BOTTOM LINE
Carpal tunnel syndrome is extremely common and is seen in both community and hospital
practice
A diagnosis of carpal tunnel syndrome should be suspected in patients with intermittent
tingling, pain, or altered sensation affecting the fingers in the distribution of the median
nerve: the thumb, index finger, middle finger, and radial half of the ring finger
Non-operative strategies may be successful for early or mild disease or where advanced
disease is associated with minimal symptoms
Where non-operative strategies fail, open carpal tunnel decompression provides good
results and high levels of reported satisfaction for most patients
SOURCES AND SELECTION CRITERIA
We searched PubMed, the Cochrane Library, and the
Cumulative Index to Nursing and Allied Health Literature
to identify source material for this review. We examined
available evidence published in the English language for
the diagnosis and treatment of carpal tunnel syndrome.
The search terms used were “carpal tunnel”, “carpal
tunnel syndrome”, “tingling fingers”, “median nerve
compression”, and “compression neuropathy”. There were
no well conducted large randomised trials. We selected and
examined smaller randomised trials as well as case series,
cohort studies, and observational reports where these
provided the only evidence.
Box 1 | Symptoms and signs of carpal tunnel syndrome
•Tingling or numbness in the hand especially in the thumb,
index finger, and middle finger
•Pain in hand, wrist, or forearm, possibly radiating as far
proximally as the shoulder
•Reduced grip strength
•Increased 2 point sensory discrimination on testing in the
median nerve distribution
•Clumsiness or reduced manual dexterity
•Wasting of the thenar eminence musculature
•Reduced thumb abduction strength (fig 1)
•Trophic ulcers at the tips of thumb, index finger, or
middle finger
patients who will experience progressively worsening
symptoms without treatment has not been satisfactorily
resolved.
How is it diagnosed?
The diagnosis of carpal tunnel syndrome is a clinical
one that may be supported by specific tests and electrophysio-logical studies. The diagnosis should be suspected in patients of any age, although it is much less
common among children and the diagnosis is less likely
to be idio-pathic.10 Patients commonly report intermittent
tingling, pain, or altered sensation of the fingers in the
distribution of the median nerve: the thumb, index finger,
middle finger, and radial half of the ring finger (box 1).
These symptoms may extend atypically to include the little
finger or may manifest as less well localised symptoms in
the forearm, radiating as far proximally as the shoulder.
Where symptoms are isolated to the ring and little fingers,
a diagnosis of carpal tunnel syndrome is less likely.
Permanent sensory change as well as motor signs
and symptoms are late manifestations of carpal tunnel
syndrome. More severe disease may also present with
unremitting sensory symptoms, thenar muscle wasting (fig 2), or weakness. Patients may become aware of
reduced dexterity with fine tasks such as doing up buttons or become clumsy and drop items. Patients may
the bmj | 8 November 2014 27
EDUCATION CLINICAL REVIEW
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Fig 1 | Testing thumb abduction strength: the patient is asked to
place his or her hand on a table with the palm facing upwards
and the thumb abducted (pointing to the ceiling). The examiner
palpates the thenar abductor pollicis brevis musculature for
muscle bulk, evidence of active contraction, and strength of
contraction while at the same time providing resistance to the
patient’s active thumb abduction. Comparison is made with the
contralateral side
Fig 2 | Thenar muscle wasting
relate their symptoms to their occupation, particularly
where this involves heavy manual or repetitive hand and
wrist actions. Examination may identify trophic ulceration to the pulps or tips of affected fingers, representing
loss of protective sensation.
Weakness of thumb abduction is tested by assessing
the abductor pollicis brevis muscle. Tinel’s sign (fig 3),
the modified Phalen’s test (fig 4), and Durkan’s compression test (fig 5) are provocative tests commonly used to
support a diagnosis of carpal tunnel syndrome. These
tests are considered to be more supportive of the diagnosis where two or all of them show abnormal results, but
they are less reliable when used individually, with wide
variation in their reported sensitivity and specificity.11
The combination of the history, examination, and
results of these specific tests will lead clinicians to a subjective impression of the likelihood of carpal tunnel syndrome as a clinical diagnosis. The most likely diagnosis
is often carpal tunnel syndrome because of its considerable prevalence; however, the condition can be confused
with other diseases (box 2). These should be considered
as alternative or additional diagnoses depending on the
presentation and age of the patient.
The median nerve can be the object of focal compression or irritation at more than one site along its anatomical
course. The second nerve lesion occurs most commonly
in the cervical spine. Clinical examination of the cervical spine is usually enough to establish whether there is
any important degenerative change at a relevant spinal
level in patients who do not have any neck symptoms or
signs. Patients with degenerative changes of the cervical
spine may report pain, altered sensation, or motor signs
in an atypical distribution for carpal tunnel syndrome and
localised neck pain or stiffness, or both, as well as variation in their symptoms depending on cervical position or
movement. Where there is diagnostic doubt or concern
Box 2 | Differential diagnoses for carpal tunnel syndrome
•Cervical radiculopathy—suggested by exacerbation of symptoms on neck movement, neck
pain, and atypical patterns of neurological involvement
•Diabetes mellitus—the resulting polyneuropathy should be suspected where symptoms relate
to both the arms and the legs or reflexes are lost or diminished, or both
•Hypothyroidism— the resulting polyneuropathy should be suspected where symptoms relate
to both the arms and the legs or reflexes are lost or diminished, or both
•Osteoarthritis of the small joints of the hand—painful and stiff small joints of the hand may
coexist with carpal tunnel syndrome
•Inflammatory arthropathy of the small joints of the hand—this may coexist with carpal tunnel
syndrome. Look for features of systemic disease as well as joint specific symptoms
•Vibration white finger or hand-arm vibration syndrome—use of vibrating tools can be
established from the history
•Other peripheral neuropathies—these should be suspected where symptoms relate to both
the arms and the legs or reflexes are lost or diminished, or both
•Raynaud’s phenomenon—a relation should be sort between symptoms and exposure to cold
•Motor neurone disease—will not usually have a sensory component
•Ulnar nerve compression—usually presents in the distribution of the ulnar nerve
28 Fig 3 | Tinel’s sign. The patient is asked to place his or her wrist
on a table in the supine position. The examiner uses his or her
index or middle finger to gently but firmly tap proximally from
the palm to a point proximal to the wrist flexor retinaculum and
in the line of the median nerve, aiming to reproduce tingling,
numbness, or pain in the thumb, index finger, and middle
finger (median nerve distribution)
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EDUCATION CLINICAL REVIEW
Fig 5 | Durkan’s compression test. The patient is asked to place
his or her wrist on a table in the supine position. The examiner
places three fingers over the carpal tunnel and compresses this
area for 30 seconds. A test result is positive or abnormal if the
patient reports tingling, numbness, or altered sensation in the
thumb or index finger, middle finger, or radial half of the ring
finger (median nerve distribution)
Fig 4 | Phalen’s test. The
patient is asked to actively
and maximally flex his or
her wrist. The position is
maintained for 60 seconds
or less if that is the extent
it can be tolerated. The test
result is positive or abnormal
if there is tingling, pain,
or altered sensation in the
patient’s thumb or index
finger, middle finger, or
radial half of the ring finger
(median nerve distribution).
It is possible to test both
sides by asking the patient
to place both hands back to
back while flexing the wrists
and dropping the elbows to
increase the degree of wrist
flexion
that degenerative changes in the cervical spine may be the
cause of symptoms, these patients should be referred to a
specialist clinic. Cervical spondylosis is not a bar to investigation or treatment for carpal tunnel syndrome, although
patients should be counselled that they may experience
incomplete relief of symptoms or no improvement at all
depending on the balance of cervical versus carpal tunnel
involvement.
How is it investigated?
Once a diagnosis of carpal tunnel syndrome has been
made, clinicians should attempt to identify a specific
cause for the symptoms. Any reversible or transient
causes dealt with may contribute to an improvement or
resolution of the carpal tunnel symptoms. Secondary
causes of carpal tunnel syndrome include hypothyroidism; pregnancy; bleeding into the carpal tunnel, associated with haemophilia or minor trauma; and space
occupying lesions within the carpal tunnel itself, causing local nerve compression, such as ganglions or cysts.
Although rheumatoid arthritis, diabetes, and hypothyroidism are thought to be associated, it is neither useful
nor cost effective to screen patients presenting with carpal
tunnel symptoms with radiography or glucose or thyroid
function tests in the absence of other clinical evidence
of the disease.12
There is debate about the place of electrophysiological
testing in carpal tunnel syndrome. The American Academy of Orthopaedic Surgeons recommends the routine
use of electrophysiological testing to confirm a diagnosis
of carpal tunnel syndrome.13 Guidelines by the British
Society for Surgery of the Hand, which are currently being
reviewed, recommend that electrophysiological testing
should be used to substantiate the diagnosis only in
specific situations or where there is diagnostic doubt.14
Guidelines for healthcare commissioning by the British
Society for Surgery of the Hand, the British Orthopaedic
Association, and the Royal College of Surgeons recom-
mend that electrophysiological testing should be reserved
for situations where there is diagnostic doubt, complex
cases, or where there are recurrent symptoms after initial
surgery, and that testing is best undertaken in a specialist
centre.15
The techniques used in the electrodiagnostic studies
vary and the false negative rate is estimated to be in the
order of 5%.16 Debate therefore centres on cost effectiveness. One well organised prospective study found that
electrophysiological testing significantly influenced
patient selection for surgery and the surgical plan.17
Although electrophysiological studies are useful, we
suggest that they are not required to make an initial
diagnosis of carpal tunnel syndrome or to initiate management in the primary care environment. Their use is
better suited to assessment in a specialist environment,
for patient selection for surgery, and for evaluation of
complex cases, relapse of symptoms, or recurrence. Their
usefulness is to confirm a median nerve lesion, localise
the lesion to the carpal tunnel rather than to another site
such as the cervical spine, exclude other causes of neuropathy, and form a baseline for nerve function before
treatment. This baseline assessment of nerve function can
be particularly useful should patients fail to improve after
surgery.
How is it managed?
Several treatments for carpal tunnel syndrome have been
advanced, recommended, and studied, although evidence to support these is of variable quality. Treatments
are directed at both the relief of symptoms and the prevention of future deterioration.
Wrist splinting
A large volume of low level evidence suggests that wrist
splinting in a neutral position (0° of extension) can alleviate the symptoms of carpal tunnel syndrome. These
studies are generally poorly randomised or blinded but
the bmj | 8 November 2014 29
EDUCATION CLINICAL REVIEW
do report symptomatic improvements in several small
studies with four weeks of wrist splinting, resulting in
few complications.18
Good evidence suggests that carpal tunnel syndrome is
not necessarily progressive and that the simple method
of splinting is all that is sometimes required to control
symptoms. One small randomised controlled trial of 176
patients compared patient satisfaction and outcomes
in patients with a confirmed diagnosis of carpal tunnel
syndrome who were randomised to splinting or to surgery. Splinting provided adequate relief of symptoms and
avoided surgery for 37% of patients.19
Corticosteroid injection
Injection of steroid into the carpal tunnel is commonly
used for the treatment of carpal tunnel syndrome and as
a diagnostic tool. It is widely thought to offer good relief
of symptoms for patients with mild to moderate disease, particularly for pain.20 21 Evidence also supports
the use of oral steroids in the treatment of carpal tunnel
syndrome,22 although the systemic effects of these drugs
generally preclude their regular use in modern practice.
Several small cohort studies examining corticosteroid
injection into the carpal tunnel have had mixed results.
One such study of 23 patients reported sustained relief of
symptoms in 11% of patients after 18 months.23 A recent
randomised controlled trial compared three groups (37
patients each) receiving 80 mg methylprednisolone
steroid injection, 40 mg methylprednisolone steroid
injection, and placebo and found that steroid injections
improved symptom scores at 10 weeks but that there was
no difference with placebo at one year.24 Overall, 75%
of the patients had surgery within one year. The results
of carpal tunnel injection are reported to be worse for
patients with more clinically severe disease, those with
diabetes, older people, and where symptoms are permanent or unremitting.14
Injection into the carpal tunnel is safe20; however, there
is a small risk of injury to or even injection within the
nerve.20 21 A good response to carpal tunnel injection is
often thought to indicate the potential for a good response
to surgery, although the evidence for this is poor and there
is no consensus on dose or preparation of steroid injection.21 The practice of treating relapse after carpal tunnel
injection with a further injection is not supported by good
evidence.20
Therapy
Carpal tunnel syndrome is often treated using rest or
modification of activity, physiotherapy, tendon and nerve
gliding regimens, mobilisation of the carpal bones, or
stretching programmes. However, the evidence to support these regimens is poor.
There is no good evidence to support the use of diuretics, magnets, vitamins, or acupuncture in the treatment
of carpal tunnel syndrome. A small but well organised
randomised and double blinded study in 45 people with
bilateral carpal tunnel syndrome confirmed by electroneurography did show evidence that ultrasound treatments may provide short to medium term relief of mild to
moderate symptoms.25
30 ADDITIONAL EDUCATIONAL RESOURCES
Resources for healthcare professionals
O’Connor D, Marshall S, Massey-Westropp N. Nonsurgical treatment (other than steroid injection) for
carpal tunnel syndrome. Cochrane Database Syst Rev
2003;1:CD003219
Marshall S, Tardif G, Ashworth N. Local corticosteroid
injection for carpal tunnel syndrome. Cochrane Database
Syst Rev 2007;2:CD001554
Scholten RJ, Mink van der Molen A, Uitdehaag BM,
Bouter LM, de Vet HC. Surgical treatment options for
carpal tunnel syndrome. Cochrane Database Syst Rev
2007;4:CD003905
British Orthopaedic Association, British Society
for Surgery of the Hand, Royal College of Surgeons.
Commissioning guide: treatment of painful tingling
fingers. 2013
Resources for patients
British Society for Surgery of the Hand online
patient resource (www.bssh.ac.uk/patients/
commonhandconditions/carpaltunnelsyndrome)
—An online patient information leaflet about the causes,
symptoms, and treatments for carpal tunnel syndrome
American Society for Surgery of the Hand information
for public and patients (www.assh.org/Public/
HandConditions/Pages/CarpalTunnelSyndrome.aspx)
—An online patient resource provided by the Public
Education Division of the American Hand Society; provides
information about the nature, diagnosis, and treatments
available for carpal tunnel syndrome
A patient resource for and about carpal tunnel syndrome
(www.carpal-tunnel.net)
—An expert resource consolidating information, trials,
and evidence related to the diagnosis, investigation, and
treatment of carpal tunnel syndrome
NHS Patient Choices (www.nhs.uk/conditions/carpaltunnel-syndrome/Pages/Whatisit.aspx)
—A British National Health Service resource for patients
with interactive animations explaining carpal tunnel
syndrome, and direct comments, feedback, and
discussion from patients and carers
All the websites have free access
Surgery
Carpal tunnel decompression is a well established surgical treatment for carpal tunnel syndrome. It is usually
undertaken as a day case procedure under local anaesthesia. Several large retrospective cohort studies have
reported good outcomes and high levels of patient satisfaction after decompression surgery; however, there
are potential complications. These include a potentially
tender scar, persistent symptoms, neurovascular injury,
wound complications, bleeding, pillar pain (a deep aching pain at the base of the thenar eminence and across
the wrist), and reduced grip strength. Of these, most are
rare and of the order of <1%; however, scar tenderness
and pillar pain are reported in 7% and 18% of patients,
respectively and may persist for up to two years.26
As with most surgical interventions, the technical procedure for carpal tunnel decompression varies. Release
of the flexor retinaculum may be combined with a tenosynovectomy, neurolysis of the median nerve, or length8 November 2014 | the bmj
EDUCATION CLINICAL REVIEW
ening or reconstruction of the flexor retinaculum. There
is no good evidence of additional benefit for any of these
specific variations for the treatment of idiopathic carpal
tunnel syndrome.27
Between 70% and 90% of patients undergoing carpal tunnel decompression are estimated to obtain a
good long term result and report high levels of satisfaction.27 28 One survey found that most patients reported
being satisfied and free from symptoms of carpal tunnel
syndrome at an average of 13 years after open carpal
tunnel decompression.29
One well constructed systematic review identified that
poor outcomes were associated with diabetes mellitus,
poor health status, thoracic outlet syndrome, double
crush nerve injury, alcohol misuse, smoking, workers’
compensation cases with outstanding litigation, normal
preoperative nerve conduction studies, and noticeable
preoperative wasting of the abductor pollicis brevis muscle.28 Patient age, weight, and sex were not found to be
relevant predictors of outcome, although patient satisfaction was more unpredictable for elderly patients (aged 70
years or more).30 The improvement of symptoms in very
elderly patients has often been reported to be incomplete.
Despite this, elderly patients (aged 80 years or more) with
advanced disease do report considerable relief of pain
and high levels of satisfaction after carpal tunnel decompression, although grip strength may not improve.31 32
The carpal tunnel can also be decompressed using an
endoscopic technique. The published results for this technique are equivalent to those for standard open decompression, although these results relate to procedures
undertaken by experts. Endoscopic surgery remains a
specialist technique and has not been shown to provide
superior outcomes. One stated advantage is the avoidance
of a palmar wound, which may be more comfortable for
patients. One well structured randomised controlled trial
confirmed this benefit for endoscopic surgery. However, the
improvement was marginal at best compared with patients
undergoing standard open carpal tunnel decompression.33
There has been considerable debate as to whether
patients with bilateral carpal tunnel symptoms selected
for surgery should undergo staged or concurrent surgery.
The concern is that concurrent surgery may leave them
exposed to major functional limitations and should they
experience a complication, this could be particularly
disabling. One small but well structured patient cohort
study followed up separate cohorts of patients with
bilateral symptoms selected for staged (33 patients) and
concurrent surgery (30 patients). Both groups reported
high levels of satisfaction and good outcomes; however,
patients treated with concurrent surgery showed greater
functional impairment postoperatively. Far fewer of the
patients selected for concurrent surgery reported that
they would be happy to repeat this choice given the
chance.34
What is the approach to management in primary care?
Once a diagnosis of carpal tunnel syndrome is made,
wrist splinting in a neutral position is a reasonable first
step in management. This can be particularly effective for
symptoms at night.
Box 3 | When should I refer?
•Diagnostic uncertainty
•Failed conservative treatments
•Severe symptoms or noticeable functional limitation
•Relapse after successful carpal tunnel injection
•Recurrence after carpal tunnel surgery
•Request by patient
Steroid injection of the carpal tunnel is a practical
option in the primary care environment but should be
undertaken by an appropriately trained clinician. The
available evidence suggests that patients who will obtain
benefit from wrist splinting or carpal tunnel injection
are able to report this within four weeks.18 20 Failure to
respond by this time should prompt reassessment and
consideration for referral. Box 3 outlines when to consider patients for referral.
Some general practitioners in the community or
general practitioners with a specialist interest in hand
surgery have training and experience in carpal tunnel
surgery. Where surgery is offered outside specialist hand
centres this should be supported with access to electrophysiological testing and specialist hand surgeons.
What is the approach to management in hand surgery
centres?
All of the options for management available in the community remain options for treatment. Electrophysiological testing is useful for localising the disease to the carpal
tunnel, quantifying the severity of disease, and providing a baseline for assessment of recovery. Electrophysiological testing is also useful where there has been no
improvement in symptoms after surgery or where symptoms recur after an initial period of relief.
The evidence for repeated steroid injection after relapse
is limited.21 Suitable patients should be offered surgical
decompression, which can usually be achieved under
local anaesthesia.
Contributors: REA and SDM contributed equally to the design, literature
review, and production of the paper. REA will act as guarantor.
Competing interests: We have read and understood the BMJ policy on
declaration of interests and declare the following interests: none.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent: Obtained.
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decompression. J Hand Surg Eur Vol 2013;39:627-31.
ANSWERS TO ENDGAMES, p 38
For long answers go to the Education channel on thebmj.com
STATISTICAL
QUESTION
Sample size: how many
participants are needed in
a cohort study?
Statements a, b, and c are all true.
ANATOMY QUIZ
Sagittal computed
tomography angiogram of
the abdomen with contrast
A: Right deep inferior epigastric
artery
B: Right deep inferior epigastric
artery perforator
C: Right rectus abdominis muscle
D: Right external iliac artery
E: Right kidney
32 PICTURE QUIZ
A 16 year old boy with chest pain
1 Sinus rhythm at 58 beats/min, normal axis, ST elevation in leads
II, III, and aVF, with reciprocal ST depression in leads I and aVL.
Appearances are consistent with an inferior ST elevation myocardial
infarction (STEMI).
2 Causes of ST elevation in young people include “high take off,”
myopericarditis, and acute STEMI. Causes of myocardial infarction
in young people include coronary thrombosis or embolus,
accelerated atherosclerotic disease (for example, in familial
hypercholesterolaemia), coronary or aortic vasculitis, coronary
spasm, congenital coronary abnormalities, and cardiac abnormalities
such as a patent foramen ovale and aortic or coronary dissection.
3 Antiplatelet treatment with aspirin and an ADP receptor blocker such
as ticagrelor, prasugrel, or clopidogrel should be started provided
there are no contraindications. Opiate pain relief with antiemetic
cover and nitrates for vasodilation should also be given. Any hypoxia
should be corrected with oxygen therapy.
4 Urgent transfer to a tertiary centre for coronary angiography.
Subsequent treatment will depend on the confirmed diagnosis and
the condition responsible.
8 November 2014 | the bmj