A Review

Current diagnosis and management of carpal
tunnel syndrome: A review

Introduction
Carpal tunnel syndrome (CTS) is a neuropathic syndrome related to the compressed median nerve in the
carpal tunnel, under the transverse carpal ligament.
The median nerve gives innervation to

the small muscles of the hand and sensory
innervation to the fingers, which
control the touch sensation and reflexes
for the right motor function, especially
the hand grip.
The carpal tunnel protects the median nerve and 9 tendons
that act to flex the fingers:
• 1 tendon of flexor pollicis longus (FPL) : flexes
interphalangeal joint of the distal phalanx of the thumb.
• 4 tendons of flexor digitorum profundus (FDP) : flexes
the metacarpophalangeal and distal interphalangeal
joints of the index, middle, ring, and little fingers.
• 4 tendons of flexor digitorum superficialis (FDS) :
flexes the middle phalanges of the medial four digits at
the proximal interphalangeal joints
Lifestyle Work Genetic
Risk factors
Age Sex Injury

Pathophysiology Increased carpal tunnel presure
Carpal tunnel syndrome occurs due to an Median nerve compression and entrapment
increased interstitial pressure within the carpal
tunnel ultimately resulting in compression and
injury of the median nerve.
Change of microvascular structure of nerve
Biochemical disturbance
The theory of microvascular insufficiency
states that the reduced blood supply causes the Reduction in the endoneural blood flow
lack of oxygen and nutrients to the nerves, so Incrased permeability of
they lose the ability of the nerve impulse endoneural vessels
transmission. The ischemia probably plays an Edema
important part in the pathogenesis of CTS. Increeased diffusion distance for
oxygen
Hypoxia
Axonal degeneration of nerve and neuritis

Diagnosis
Anamnesis Physical Supporting

examination examination
Anamnesis
Complain of tingling, Fingers that are usually affected

numbness, and pain that are the thumb, digits 2 and 3, and
exacerbates at night. the radial half of the digit 4.
Weakness, stiffness, and

the change in temperature
Physical Examination
• A decreased pain sensation (hypoalgesia) can be • The two provocative tests commonly used to
found on the palmar side of the index finger and it diagnose CTS are Phalen’s test and Tinel’s test.
contrasts with the ipsilateral little finger on the
effected hand.
+ If a patient feels pain or

paresthesia in the radial
+ If a patient feels any soreness
side of the ring finger,
or paresthesia in the median nerve
middle finger, index, and
distribution
thumb, which are
innervated by the median
nerve
Supporting Examination
Electrodiagnostics nerve conduction studies : NCS is judged as the gold standard in the CTS
(NCS) diagnosis since it provides information about median
nerve’s physicological health over the carpal tunnel
Electromiogram (EMG) : EMG assesses pathologic changes in the muscles

innervated by the median nerve, typically the
abductor pollicis brevis muscle.
Ultrasound (USG) : The use of ultrasound has been implicated in the diagnosis of CTS because thickening
of the median nerve, flattening of the nerve within the tunnel and bowing of the flexor
retinaculum are all features diagnostic of CTS.
Grading based on
electrodiagnostic studies
Severity of CTS Findings on EDX Intervention
CTS with no median neuropathy

No Treat the symptoms
at the wrist
Abnormality in comparison studies or

Mild Treat the symptoms
median sensory nerve
Prolonged distal motor latency to the

abductor pollicis brevis with normal Injection/surgery with
Moderate
amplitude of APB CMAP progressivity
Criteria on the above plus either

decrement of median to APB
Severe CMAP amplitude and/or needle Surgery if no contraindication
EMG abnormality in the thenar
muscles
Treatment
1. Non-Invasive
2. Invasive
3. Alternative
therapy
Non-Invasive treatment
Education
Ultrasound (USG)
therapy
Non-Pharmacological
treatment
Mobilization Mild CTS: a

exercise wrist splint at
night
Non-Invasive treatment
Pharmacological As a first line pharmacological management, clinicians can give nonsteroidal anti-inflammatory
treatment drugs (NSAIDs) to relieve pain in CTS patients. Oral steroids and vitamin B6 can be given as
second line therapy.
Analgesic drugs may not be effective if administered alone, without combining with other
drugs, e.g., gabapentin, amitriptyline, diazepam, and vitamins, including B1, B6, and B12 for
chronic pain. Combination of analgesic drugs will remarkably lower the adverse effect.
Amitriptyline gives better results as treatment for sensory symptoms in early CTS.
Gabapentin gives notable analgesia in some neuropathic pains such as trigeminal neuralgia,
but A study review recommends no significant advantage of gabapentin use for symptomatic
relief or power strength improvement in mild-to-moderate CTS patients.
Wrist steroid injections are often successful to treat patients with CTS. This
therapy has been known as a well-studied and potent intervention for mild and
moderate CTS patients.
Dexamethasone 1–4 mg or hydrocortisone 10-25 mg or methylprednisolone 20- 40 mg
is injected into the carpal tunnel using a 23 or 25G needle at 1 cm proximal to the wrist
crease medial to the palmaris longus tendon at an angle of 30o. The injections can be
repeated in 7 to 10 days for a total of three or four injections. Injections should be
used with caution in patients under 30 years of age.
Surgery should be considered if the symptoms persist and there is no relief, or if the
motor or sensory deficiency persists. Surgery might be indicated when the symptoms
persist for more than six months without any relief with non-surgical treatment.
Invasive treatment
• One of the surgical techniques is carpal tunnel release (CTR) consisting of open surgery
and endoscopic techniques. Endoscopic carpal tunnel release surgery (ECTR) has
considerably gained popularity during the last two decades because of speedy recovery and less
pain with no negative outcomes.
• A study showed that the reported results and two-point discrimination test related to ulnar
nerve symptoms showed improvement after open carpal tunnel release (OCTR). ECTR and
OCTR, both offer satisfactory results in pain relief, patient satisfaction, relief duration, and
adverse effects
Alternative Therapy
Acupuncture effectively relieves pain, numbness, inflammation, and returns motor function.
Acupuncture
Electromyography established good results, including noticeable improvements in some
parameters, such as sensory nerve conduction velocity, sensory amplitude, median nerve
sensory latency, motor latency, motor nerve conduction pace, and motor amplitude
The point selection is based on the anatomy and the abnormality location in median nerve.
Gabapentin gives notable analgesia in some neuropathic pains such as trigeminal neuralgia,
but A study review recommends no significant advantage of gabapentin use for symptomatic
relief or power strength improvement in mild to moderate CTS patients.
Cupping therapy Cupping therapy has been used to reduce pain
Dry needling Dry needling (DN) is useful for overcoming pain. Dry needling is usually utilized as a treatment
for any neuromusculoskeletal pain syndromes involving ligaments, muscles, tendons,
subcutaneous fascia, peripheral nerves, scar tissue, and neurovascular bundles.
Thank you!

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A Review

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Current diagnosis and management of carpal

tunnel syndrome: A review

The median nerve gives innervation to

Age Sex Injury

Axonal degeneration of nerve and neuritis

Anamnesis Physical Supporting

Complain of tingling, Fingers that are usually affected

Weakness, stiffness, and

+ If a patient feels pain or

Electromiogram (EMG) : EMG assesses pathologic changes in the muscles

Severity of CTS Findings on EDX Intervention

CTS with no median neuropathy

Abnormality in comparison studies or

Prolonged distal motor latency to the

Criteria on the above plus either

Mobilization Mild CTS: a

Cupping therapy Cupping therapy has been used to reduce pain

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